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PubMed2005

Sonographic evaluation of plantar fasciitis and relation to body mass index.

PURPOSE: We have investigated the role of sonography in the diagnosis of plantar fasciitis. MATERIALS AND METHODS: This study evaluates 39 patients with plantar fasciitis and control group of 22 healthy volunteers. The plantar fascia thickness was measured 5 mm distal to the insertion of the calcaneus of plantar aponeurosis. Qualitative parameters such as decreased echogenity, biconvexity, perifascial fluid and calcification of plantar fascia were also noted. RESULTS: Mean plantar fascia thickness was measured 2.9 mm in patients with unilateral heel pain, 2.2 mm for contralateral normal heel and 2.5mm for control group. There was a statistically significant difference between heel with plantar fasciitis, contralateral normal heel and control groups (p=0.009 and 0.0001, respectively). Mean body mass index was 28 kg/m(2) in patients with heel pain and 25 kg/m2 in control group. Body mass index measurements were significantly different between plantar fasciitis and control groups. We found reduced plantar fascia echogenity in 16 cases (41%), calcaneal spur in 20 cases (51%), biconvex appearance in two cases (5.1%) and perifascial fluid in one case (2.5%). CONCLUSION: We conclude that in patients with plantar fasciitis, ultrasound may detect relatively small differences in plantar fascia thickness even in clinically unequivocal plantar fasciitis.

Adolescent↗
PubMed1999

Necrotizing fasciitis in infancy: an uncommon setting and a prognostic disadvantage.

Necrotizing fasciitis is a potentially fatal, progressive soft tissue infection that typically occurs in adults, and only rarely occurs in infants. Although adults in whom necrotizing fasciitis develops are commonly diabetic, malnourished, or otherwise immunocompromised, infants in whom the disease develops are typically healthy and without clear predisposing factors. Herein, however, the authors report the case of an infant with compromised immunity secondary to the manifestations and treatment of panhypopituitarism, in whom postoperative necrotizing fasciitis developed after bilateral inguinal herniorrhaphy. The diagnosis, pathological mechanism, and treatment of necrotizing fasciitis are reviewed and the distinguishing features in infants are highlighted. The combination of a low incidence and very high mortality rate associated with necrotizing fasciitis in this subgroup strengthens the need for hypercritical suspicion. Early diagnosis and the prompt initiation of surgical treatment are the most essential means to improve on the prognosis for necrotizing fasciitis in infants.

Adipose Tissue↗
PubMed1997

Staphylococcal necrotizing fasciitis in the mammary region in childhood: a report of five cases.

OBJECTIVE: Necrotizing fasciitis is a highly lethal soft tissue infection rarely reported in childhood. The initiating site is usually a local trauma or a surgical wound. We observed five cases of necrotizing fasciitis the initiating site for which was the mammary region and discuss their management. STUDY DESIGN: We describe these five patients and review the clinical characteristics of their presentation. RESULTS: Staphylococcal necrotizing fasciitis was observed in the mammary region in all five cases. Four children were newborn infants with a mammitis preceding the onset of necrotizing fasciitis. Surgical débridement was done only after the fourth day from onset of illness. All children were discharged in good condition after 1 month. Two have been followed until puberty, with destruction of the mammary gland in one case and good development in the other one. CONCLUSION: Mammitis may be the initiating event for necrotizing fasciitis in neonates. Necrotizing fasciitis is a life-threatening disease; patients require early intensive care, parenteral antibiotic therapy, and surgical débridement. In a few instances surgery can be carefully delayed until the necrotic area is more delineated if the condition is diagnosed early during disease evolution and appropriate treatment is instituted in intensive care units.

Anti-Bacterial Agents↗
PubMed1997

Necrotizing fasciitis after cesarean delivery.

OBJECTIVE: To review our experience with the diagnosis and management of necrotizing fasciitis after cesarean delivery. METHODS: We reviewed medical records of women with serious post-cesarean wound infections at the University of Alabama at Birmingham between 1987 and 1994 to identify women with necrotizing fasciitis. The diagnosis of necrotizing fasciitis required intraoperative identification of necrotic fascia in febrile women undergoing post-cesarean wound debridement. RESULTS: During the study period, 5048 women had cesarean deliveries, nine of which were complicated by necrotizing fasciitis. The mean (+/-standard deviation) maternal age was 27 +/- 6 years, and the mean maternal weight was 199 +/- 64 lb. None of the patients had insulin-dependent diabetes mellitus, and none had known peripheral vascular disease. There were no intraoperative complications at cesarean delivery. The mean time from cesarean delivery to the diagnosis of necrotizing fasciitis and reoperation was 10 +/- 4 days (range 5-17). All patients had surgical debridement upon consideration of the diagnosis, and all received broad-spectrum antimicrobial therapy. Results of wound cultures were available in seven of the women, and all seven were found to have polymicrobial infections. There were two mortalities, one as a result of metastatic breast cancer and another with complications of sepsis. CONCLUSION: Necrotizing fasciitis is infrequent (1.8 per 1000 women) after cesarean delivery at our institution, but it does result in appreciable morbidity and mortality.

Adolescent↗
PubMed2003

Eosinophilic fasciitis and eosinophilic cellulitis in a patient with abnormal circulating clonal T cells: increased production of interleukin 5 and inhibition by interferon alfa.

Eosinophilic fasciitis (Shulman's syndrome) and eosinophilic cellulitis are part of a spectrum of diseases characterized by tissue and peripheral blood eosinophilia. Eosinophils are implicated directly in the lesional process that characterizes these conditions, because signs of eosinophil activation and degranulation are observed at the sites of tissue injury. The cause and pathogenesis of eosinophilic fasciitis and cellulitis are presently unclear. Herein, we report a patient manifesting rapidly progressive localized cutaneous induration of the arms and legs with eosinophilia, no signs of systemic sclerosis, and histopathologic features compatible with the diagnosis of eosinophilic fasciitis. Four years after the onset of eosinophilic fasciitis, the patient had recurrent episodes of eosinophilic cellulitis. Blood screening for clonal T-cell receptor gamma gene rearrangements revealed several amplified clonal populations of circulating T cells. Furthermore, in vitro analysis of cytokine production by the patient's peripheral blood mononuclear cells demonstrated strongly increased production of interleukin 5, the synthesis of which could be completely blocked by interferon (IFN)-alpha. The coexistence of eosinophilic fasciitis and cellulitis in a patient with an abnormal circulating T-cell clone and increased IL-5 production are unique and might be responsible for the eosinophilia and eosinophil-mediated tissue injury. Although not assessed in vivo in this patient, our in vitro data provide a rationale for the use of IFN-alpha in eosinophilic fasciitis and/or cellulitis.

Aged↗
PubMed1999

Nodular fasciitis and solitary fibrous tumor of the oral region: tumors of fibroblast heterogeneity.

OBJECTIVE: Fibroblastic proliferations of the oral cavity are extremely varied, yet they share certain features-spindle cell morphology, collagen synthesis, and fasciculation. Nodular fasciitis is a cellular fibroblastic lesion, uncommonly located in the oral submucosa, that shows smooth muscle actin (SMA) immunoreactivity. Solitary fibrous tumor expresses a CD34 fibroblast phenotype. The aim of this study is to report instances of nodular fasciitis and solitary fibrous tumor in the orofacial region and investigate immunohistochemical markers to compare and contrast fibroblastic phenotypic heterogeneity in these tumors. STUDY DESIGN: Seven benign cellular fibrogenic tumors initially diagnosed as nodular fasciitis over a 10-year period were examined. Immunohistochemical markers, including S-100 protein, SMA, CD68, CD34, and vimentin, were used to further characterize these lesions. RESULTS: All tumors occurred in adults, and the buccal mucosa was found to be the favored site. The spindle cells in these tumors showed phenotypic heterogeneity both within and between tumors. All were vimentin-reactive and harbored small populations of CD68-positive macrophage/dendrocytes. Five tumors were SMA-positive and CD34-negative; the tumor in one case was SMA-negative and CD34-positive, and that in another was SMA-positive and CD34-positive. CONCLUSION: Although rare, nodular fasciitis and solitary fibrous tumor arise in oral submucosa, usually in the cheek. The histopathologic features and immunomarkers indicative of myofibroblastic differentiation are seen in nodular fasciitis, whereas solitary fibrous tumor is CD34-positive; however, one instance was found to be positive for both markers. All of these cases harbored subpopulations of CD68-positive cells. Immunomarkers are a valuable adjunct in differentiating nodular fasciitis from solitary fibrous tumor, yet some tumors may harbor heterogeneous fibroblast phenotypes.

Actins↗
PubMed2006

Zygomycotic necrotizing fasciitis in immunocompetent patients: a series of 18 cases.

Necrotizing fasciitis is most often associated with bacterial infections. Zygomycosis is an uncommon infection causing necrotizing fasciitis. We report 18 such cases of zygomycotic necrotizing fasciitis, of these, 15 were immunocompetent. Of the eight cases cultured, five were positive for Apophysomyces elegans. A retrospective case review conducted at a tertiary referral center, from 1998 to 2004, 18 cases of fungal necrotizing fasciitis were diagnosed based on histomorphology of fungal organisms; and in few of the cases diagnosis was supported by mycologic culture reports. Of the total of 18 cases, culture report was available in eight cases, and out of which five of them grew A. elegans. Fifteen patients were immunocompetent. Clinical presentation, mycologic findings and histopathologic results were evaluated. A review of the literature pertaining to A. elegans infection was also done. Histopathologic examination showed broad, predominantly aseptate and occasional pauciseptate, thin-walled fungal hyphae with occasional angioinvasion. To the best of our knowledge, this is the first largest series of zygomycotic necrotizing fasciitis from India. Herein, we present data on 18 cases of necrotizing fasciitis assosiated with zygomycosis. Most of the cases in our series were immunocompetent. Nonsuppurative necrosis with presence of typical fungal profiles was important histologic feature. Zygomycosis must be considered in the differential diagnosis not only in immunocompromised patients but also in the absence of any underlying disorders.

Adult↗
PubMed2000

Ossifying fasciitis.

A case of ossifying fasciitis occurring in the left femoral region of a 57-year-old male is reported. The patient complained of pain in his left lower extremity which was the site of previous catheterization. During a left femoropopliteal by-pass, a firm and cylindric mass measuring 5 x 3 x 2.5 cm in size was found and extracted from the left groin. Histologically, a reactional lymph node and an irregularly shaped lesion extended into the perinodal fat tissue which is composed of proliferating fibroblasts with occasional mitotic activity. Within this fibroblastic proliferation, immature woven bone composed of osteoid with calcification and chondroid differentiation were seen. Metaplastic bone is an uncommon finding in cases of nodular fasciitis, parosteal fasciitis, cranial fasciitis and florid reactive periostitis. Ossifying fasciitis is known as an uncommon variant of nodular fasciitis. It is an uncommon post-traumatic benign lesion of subcutaneous tissue with an unclear etiology of ossification which is neither related with a bony structure nor contains any muscle tissue. This lesion has been reported only once previously, in the femoral region after a trauma history of catheterization.

Fasciitis↗
PubMed2002

Fulminant group A streptococcal necrotizing fasciitis: clinical and pathologic findings in 7 patients.

BACKGROUND: Necrotizing fasciitis is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Examination of deep incisional biopsy specimens can provide prompt diagnosis and improve survival. We describe 7 patients with necrotizing fasciitis caused by group A Streptococcus species. OBJECTIVE: Our purpose was to describe the unique dermatopathology and clinical features in 7 patients with necrotizing fasciitis caused by group A Streptococcus. METHODS: We conducted a retrospective review. RESULTS: The average age of the patients was 47 years. Fasciitis occurred on an extremity in all cases. All 5 patients with streptococcal toxic shock syndrome died of their disease. The histopathologic findings from early fascial disease revealed superficial epidermal necrosis, edema, and hemorrhage with few inflammatory cells, whereas clinically advanced, necrotic skin lesions revealed diffuse necrosis, thrombosis, neutrophilia, and numerous gram-positive diplococci. CONCLUSIONS: Patients with clinical features of necrotizing fasciitis should have a deep incisional biopsy specimen obtained from the central area of ecchymotic, necrotic plaques to confirm the diagnosis. Immediate surgical intervention is necessary to reduce the morbidity and mortality rates associated with necrotizing fasciitis.

Adult↗
PubMed1999

Lymph-node-based malignant lymphoma and reactive lymphadenopathy in eosinophilic fasciitis.

BACKGROUND: Lymph node enlargement in patients with eosinophilic fasciitis is a rare occurrence and its clinical significance is unknown. METHODS: The literature and authors' registries were searched for eosinophilic fasciitis associated with lymphadenopathy. Clinical data, time sequence of appearance of either disorder, and pathological diagnoses were analyzed. RESULTS: Six patients presenting with eosinophilic fasciitis had a lymph-node-based lymphoma and 4 patients had a reactive lymphadenopathy. The patients with lymphoma were elderly and the subcutaneous induration preceded the lymphadenopathy by 2 to 36 months. The patients with eosinophilic fasciitis and reactive lymphadenopathy were young and the onset of subcutaneous induration and lymph node enlargement coincided with one another. Favorable response of the eosinophilic fasciitis to prednisone therapy was attained in 3 of 3 patients with reactive lymphadenopathy and in 4 of the 6 cases with lymphoma. CONCLUSIONS: Eosinophilic fasciitis is rarely associated with clinically significant lymph node enlargement. Subcutaneous induration preceding the lymphadenopathy by 6 months or more, especially in elderly patients, suggests an underlying lymphoma. A favorable response of the subcutaneous induration to prednisone treatment does not exclude the diagnosis of lymphoma; therefore, it does not supersede the need of a pathological evaluation. A lymph node biopsy is mandatory in all cases.

Adolescent↗
PubMedDate not supplied

Burn center management of necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressive soft-tissue infection associated with significant morbidity and mortality. Necrotizing fasciitis is similar to invasive burn wound infection in that diagnosis requires histologic examination of affected tissue and treatment requires aggressive surgical debridement followed by skin autograft. Transfer to a burn center facilitates the management of necrotizing fasciitis, where requisite surgical and nursing expertise is available. We reviewed the experience of one burn center in the management of necrotizing fasciitis over a 5-year period. Ten patients were transferred to the burn center from other medical facilities for care, arriving a mean of 8.9 days after initial hospital admission. The diagnosis was made by a surgical service or consultation before transfer in all cases; initial admission to a medical rather than a surgical service delayed surgery in five cases. All patients had surgical debridement before transfer but required a mean of 5.1 additional operations at the burn center. Although the mean extent of involvement was 14.8% body surface area, the mean length of burn center stay was 34.9 days. Complications were frequent, including pulmonary failure requiring mechanical ventilation (n = 6), renal insufficiency or failure (n = 5), hypotension requiring pressers (n = 4), deep venous thrombosis (n = 3), and pulmonary emboli (n = 1). Overall mortality was 2 of 10 patients (20%). Both fatalities were associated with delay in initial surgical procedure and in transfer to the burn center. The similarity of necrotizing fasciitis and invasive burn wound infection makes the burn center the ideal setting for the treatment of this disease. We advocate the addition of necrotizing fasciitis to the list of conditions currently recognized by the American Burn Association as appropriate for burn center transfer and care.

Adult↗
PubMed2006

Community-associated methicillin-resistant Staphylococcus aureus necrotizing fasciitis in a neonate.

Neonatal necrotizing fasciitis is rare and is predominantly associated with methicillin-susceptible Staphylococcus aureus (MSSA). Necrotizing fasciitis associated with community-associated methicillin-resistant S aureus (CA-MRSA) has only recently been reported in the literature, primarily among adults. We present a case of a previously healthy neonate with necrotizing fasciitis of the back caused by CA-MRSA, pulsed-field type USA-300. We describe a 5-day-old infant with necrotizing fasciitis of the back caused by CA-MRSA. Treatment of necrotizing fasciitis requires prompt medical evaluation, prompt surgical debridement, and appropriate antibiotic selection. The potential involvement of CA-MRSA in necrotizing fasciitis in children needs to be considered before institution of antibiotics.

Community-Acquired Infections↗
PubMed2002

Intradermal nodular fasciitis of the face.

Nodular fasciitis represents reactive myofibroblastic proliferative lesions in the subcutaneous tissue, skeletal muscles, and fascia. Uncommon clinical and pathological variants of nodular fasciitis, such as intravascular, cranial, ossifying, and proliferative fasciitis, have been described. Six cases documenting a dermal location of nodular fasciitis have been reported in the English literature. Some authors have described that the histopathological features of intradermal nodular fasciitis are virtually identical to those of postoperative/posttraumatic spindle cell nodule of the skin. We herein report a 41-year-old Korean woman presenting with a 0.5 cm facial papule in which nodular fasciitis occurred in the dermis.

Adult↗
PubMedDate not supplied

Nodular fasciitis: diagnosis by fine needle aspiration biopsy.

OBJECTIVE: To describe the cytomorphologic features of nodular fasciitis that differentiate it from schwannoma. STUDY DESIGN: The cytomorphologic features of 10 cases of nodular fasciitis were compared to those of 4 cases of biopsy-proven schwannoma. Aspirate smears were evaluated for cellular cohesion, cell type and stroma. Immunoperoxidase stains were utilized in select cases. RESULTS: The cases of nodular fasciitis exhibited cohesive clusters of epithelioid to spindle-shaped cells in a background of single, intact mesenchymal cells; inflammatory cells; and myxoid stroma. In contrast, schwannomas lacked single, intact cells and inflammation. Schwannoma stroma was also myxoid but appeared more finely fibrillar, and cell clusters were notable for alternating areas of hypercellularity and hypocellularity. Immunoperoxidase stains demonstrated smooth muscle actin reactivity in 5 cases of nodular fasciitis and S-100 in 2 cases of schwannoma. CONCLUSION: Nodular fasciitis can be distinguished from schwannomas on the basis of cytomorphologic features and immunocytochemical profile. Cytologic diagnosis of nodular fasciitis is important since it obviates the need for surgical excision.

Adolescent↗
PubMed2004

Sagittal movement of the medial longitudinal arch is unchanged in plantar fasciitis.

BACKGROUND: Although a lowered medial longitudinal arch has been cited as a causal factor in plantar fasciitis, there is little experimental evidence linking arch motion to the pathogenesis of the condition. This study investigated the sagittal movement of the arch in subjects with and without plantar fasciitis during gait. METHODS: Digital fluoroscopy was used to acquire dynamic lateral radiographs from 10 subjects with unilateral plantar fasciitis and 10 matched control subjects. The arch angle and the first metatarsophalangeal joint angle were digitized and their respective maxima recorded. Sagittal movement of the arch was defined as the angular change between heel strike and the maximum arch angle observed during the stance phase of gait. The thickness of the proximal plantar fascia was determined from sagittal sonograms of both feet. ANOVA models were used to identify differences between limbs with respect to each dependent variable. Relationships between arch movement and fascial thickness were investigated using correlations. RESULTS: There was no significant difference in either the movement or maximum arch angle between limbs. However, subjects with plantar fasciitis were found to have a larger metatarsophalangeal joint angle than controls (P < 0.05). Whereas the symptomatic and asymptomatic plantar fascia were thicker than those of control feet (P < 0.05), significant correlations were noted between fascial thickness and peak arch and metatarsophalangeal joint angles (P < 0.05) in the symptomatic limb only. CONCLUSIONS: Neither abnormal shape nor movement of the arch are associated with chronic plantar fasciitis. However, arch mechanics may influence the severity of plantar fasciitis, once the condition is present. Digital flexion, in contrast, has a protective role in what might be a bilateral disease process.

Biomechanical Phenomena↗
PubMed2006

The pathomechanics of plantar fasciitis.

Plantar fasciitis is a musculoskeletal disorder primarily affecting the fascial enthesis. Although poorly understood, the development of plantar fasciitis is thought to have a mechanical origin. In particular, pes planus foot types and lower-limb biomechanics that result in a lowered medial longitudinal arch are thought to create excessive tensile strain within the fascia, producing microscopic tears and chronic inflammation. However, contrary to clinical doctrine, histological evidence does not support this concept, with inflammation rarely observed in chronic plantar fasciitis. Similarly, scientific support for the role of arch mechanics in the development of plantar fasciitis is equivocal, despite an abundance of anecdotal evidence indicating a causal link between arch function and heel pain. This may, in part, reflect the difficulty in measuring arch mechanics in vivo. However, it may also indicate that tensile failure is not a predominant feature in the pathomechanics of plantar fasciitis. Alternative mechanisms including 'stress-shielding', vascular and metabolic disturbances, the formation of free radicals, hyperthermia and genetic factors have also been linked to degenerative change in connective tissues. Further research is needed to ascertain the importance of such factors in the development of plantar fasciitis.

Biomechanical Phenomena↗
PubMed1994

Fasciitis in chronic graft-versus-host disease. A clinicopathologic study of 14 cases.

OBJECTIVE: To describe the clinicopathologic features of fasciitis in patients with chronic graft-versus-host disease (GVHD) after allogeneic bone marrow transplantation from human leukocyte antigen (HLA)-identical donors. DESIGN: A retrospective cohort study. SETTING: Tertiary care center. PATIENTS: Patients who had allogeneic bone marrow transplantation and developed chronic GVHD with clinical and pathologic signs of fasciitis. MAIN OUTCOME MEASURE: Analysis of clinical presentations and of deep cutaneo-muscular biopsy specimens. RESULTS: Between January 1974 and January 1991, 14 of 475 patients who had allogeneic bone marrow transplantation developed chronic GVHD that began with the sicca syndrome and liver or digestive tract involvement, or both, 60 to 170 days after the graft was received. Sudden and painful skin swelling was reported 350 to 3745 days after the graft was received. Follow-up over 2 to 7 years showed failure of the fasciitis to respond to steroid therapy or to any conventional treatment of chronic GVHD. Although 7 patients showed moderate improvement, the others remained functionally disabled because of skin tightness, joint stiffness, contractures, and sores. Patients with fasciitis in chronic GVHD had no specific immunogenetic profile and no history of L-tryptophan intake or phytonadione injections. CONCLUSION: Among alloimmune syndromes, fasciitis is a distinct entity that leads to functional disability. This rare form of chronic GVHD may provide clues to understanding the mechanisms involved in fasciitis from other causes.

Adolescent↗
PubMed2001

A case of proliferative fasciitis in the abdominal region.

A 20-year-old woman complained of a subcutaneous nodule accompanied by spontaneous pain and tenderness in the right hypochondriac region approximately two weeks prior to initial evaluation. The spontaneous pain and tenderness gradually worsened. Histopathological examination revealed a proliferative lesion that extended from the deep dermis to the fatty tissue and consisted predominantly of stellate or spindle-shaped fibroblast-like cells intermingled with gangliocyte-like giant cells. Consequently, proliferative fasciitis was diagnosed. Our investigation revealed only 19 cases of proliferative fasciitis reported in Japan. The overall age range of them is 20 to 75 years (mean, 57.6 years). The lesion site in them is the head and neck in 10%, the trunk in 30%, and the extremities in 60%. It follows that the extremities are predominantly the site of proliferative fasciitis, and truncal lesions are relatively rare. It is rare for proliferative fasciitis to occur at a young age or in the abdominal region. We therefore examined the differences between proliferative fasciitis and similar disorders, namely proliferative myositis and nodular fasciitis, based on summaries of cases reported in Japan.

Abdomen↗