Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Table 4 Classification, clinical aspects, anatomopathology and microbiology of necrotizing soft tissue infections[96,113-116]

	Necrotizing fasciitis	Necrotizing fasciitis	Clostridium myonecrosis (gas gangrene)	Fungal necrotizing fasciitis	Clostridium fasciitis	Progressive bacterial synergistic gangrene	Synergistic necrotizing cellulitis	Pseudomonas gangrenous cellulitis	Streptococcal myonecrosis (necrotizing myositis)
	Type 1	Type 2	Type 3	Type 4
Pain	+/++	++/+++	+++	+++	+	+++	++/+++	+/++	++/+++
Anaesthesia of lesions	In advanced stages	In advanced stages	-	-	-	-	-	-/+	-
Cutaneous signs	Edema, erythema, bullae, necrotic and ulcerated lesions	Edema, erythema, necrotic bullae	Pale, Yellow-brown discoloration of skin, Necrotico-hemorragic (brown) bullae	Edema, erythema	Minor edema, pale skin	Necrotic ulcer dusky margin and erythematous periphery at the margins of the wound	Cellulitis with foul-smelling, thick discharge from necrotic skin	Black/gray eschar.Dark discharge with surrounding erythema, hemorrhagic bullae	Edema, copper colored, blisters in advanced stage
Subcutaneous appearance of infection	Subcutaneous tissue and fascial necrosis	Subcutaneous tissue and fascial necrosis	Necrotic area composed of green-black patches.	Subcutaneous tissue, fascial and muscle necrosis		Subcutaneous tissue necrosis and gangrene	Dark pus or 'dishwasher' fliud		Seropurulent discharge
			Serosanguinous. "mousy"-smelling discharge, bluish muscles
Systemic toxicity	+ to +++	+ to +++ (Toxic shock syndrome)	+++	+++	+	+	++ to +++	+++	+ to +++ (Streptococcal Toxic Shock Syndrome)
Fever	High	High	Moderate to high	High		Minimal or absent	Moderate	High
Progression	Moderate (3-14 d)	Very fast (1-3 d)	Very fast (1-3 d)	Very fast (1-3 d)	Moderate (> 3 d)	Moderate (3-14 d)	Moderate (3-14 d)	Moderate (3-14 d)	Fast (1-4 d)
Crepitus (gas)	-/+	-	+++	++/+++	++	-	+	-	-/+
Deep fascias infection	- to ++	+ to +++	+++		+	-	- to ++	-	-/+
Muscular infection	-/+ (secondary)	-/+ (secondary)	+++		-	-	+ to +++	-	+++
Site of entry, initiating factor	Wound, vascular lesion, surgery, local infection	Trauma, surgery, cutaneous lesion, burn, erysipelas, varicella	Non penetrating trauma, limb crushing, im. injection, sepsis	Trauma, surgery	Wound, surgery	Surgery	Prior local lesions, perirectal lesions	Trauma, surgery	Trauma, surgery, muscle strain
Risk factors	Diabetes mellitus	Vascular disease	Immunosuppression	Immunosupression	Diabetes mellitus		Diabetes mellitus	Immunosupresson	Immunosupression
Miocrobiology	Enterobacteraceae, Anaerobes, Streptococcus, Staphyloccocus	Group A Streptococcus, methicillin-resistant S. aureus (MRSA)	C. perfingens	C. albicans	C. perfingens, C. septicum	Staphylococcus aureus, microaerophilic streptococci, Enterobacteriaceae	Mixed aerobes and anaerobes	Pseudomonas aeruginosa	Group A Streptococcus
			C. septicum/Vibrio spp.	C. neoformans