EUH Morning Report: What is the diagnostic criteria for necrotizing fasciitis?

The Bottom Line:

Clinical features that strongly suggest necrotizing fasciitis include¹

• signs of systemic toxicity (such as fever, hypotension, leukocytosis, or acute renal failure)
• pain out of proportion to exam (often one of the earliest signs)
• bullae or cutaneous necrosis
• tense edema
• gas in subcutaneous tissue
• loss of sensation of affected area
• rapid progression despite antimicrobial therapy

Many of these signs occur late in disease¹ and emergent surgical exploration is needed.^1,2

Definitive diagnosis can only be made by surgical exploration of the affected area, which may reveal¹

• swollen, dull-gray tissue
• stringy areas of necrosis
• thin, brownish-gray exudate, usually with no true pus (also described as used dishwater fluid)
• lack of bleeding
• noncontracting muscle
• positive “finger test” (lack of resistance to finger dissection in normally adherent tissues)

When necrotizing fasciitis is suspected, obtaining blood tests or imaging should not delay surgery.

Midtown Morning Report: How do you diagnose myocarditis and what are possible etiologies?

The Bottom Line:

Diagnosis:

• • Suspect myocarditis in patients with new-onset myocardial injury resulting in electrical or mechanical abnormalities in cardiac function in absence of acute coronary syndromes or other causes.
  • Patients commonly present with nonspecific symptoms including:
    • chest pain, dyspnea, and palpitations.
  • Often part of a pancarditis involving:
    • epicardium, pericardium, and endocardium
    • may present with pericarditis, worsening heart failure, atrial or ventricular arrhythmias, valvular dysfunction, heart block, cardiogenic shock, or sudden cardiac death.
  • Echocardiography:
    • to assess ventricular size and function to rule out other causes of cardiac dysfunction (Strong recommendation).
  • Cardiac magnetic resonance (CMR)
    • to distinguish ischemic from nonischemic cardiomyopathy.
  • Measure serum biomarkers:
    • cardiac troponin where elevated levels are supportive but not diagnostic of myocarditis.
  • Endomyocardial biopsy in patients with (Strong recommendation):
    • new-onset heart failure of < 2 weeks with normal-sized or dilated left ventricle and hemodynamic compromise (suspected fulminant lymphocytic myocarditis)
    • new-onset heart failure of 2 weeks to 3 months with dilated left ventricle and new ventricular arrhythmias, second- or third-degree heart block, or failure to respond to usual care in 1-2 weeks (suspected giant cell myocarditis)

Etiologies: