Necrotizing fasciitis (the so-called "flesh-eating disease") is a rare manifestation of infection with the group A streptococcus (Streptococcus pyogenes, though occasionally other bacteria cause it as well). Apparently, it's been a banner year for the infection in Boulder, Colorado. The Daily Camera (registration required) has the story:
Sixteen months after University of Colorado physicist Eric Cornell lost his left arm and shoulder to a rare, invasive form of strep A, at least three more otherwise healthy Boulder residents have been stricken by the same disease in the past four months.
Two who live within one-half mile of each other developed necrotizing fasciitis, otherwise known as flesh-eating bacteria, and had to have multiple surgeries to remove infected tissue. A third developed an infection in the blood and brain and died within 48 hours after first complaining of an ear infection.
"I went into the ER one night thinking I had a bad case of the flu. The next night they were telling my wife and daughters to say goodbye because I wasn't going to make it," said Robb Kimbrough, 50, who returned home from the hospital Dec. 9, after recovering from organ failure due to septic shock and having both legs amputated below the knee.
That's pretty impressive that he made it right there. Once you get to the organ failure portion, your chances of survival are pretty slim.
There seems to be disagreement over whether the incidence of invasive group A strep infections in Colorado are stable or rising:
The county does not track the incidence of invasive strep A, but chief epidemiologist Heath Harmon said judging by national estimates the county could expect to see as many as nine cases in a 12-month period. Dr. Ken Gershman, chief of the communicable disease program for the state health department, said that in the five-county Denver-metro area, which does track cases, incidence of invasive strep A definitely is on the rise, spiking from 122 cases in 2002 to 188 in 2005.
The neighbor of the lucky-to-be-alive guy also developed necrotizing fasciitis:
Regina Daly, a 39-year-old marathon runner who lives just down the road from Kimbrough up Fourmile Canyon, said she started feeling pain in her shoulder about 10 p.m. Dec. 19, but assumed it was just sore from her morning swim. By the next day, she was vomiting from the pain and had a 103-degree fever. When she fainted on the bathroom floor, her husband rushed her to the emergency room at Boulder Community Hospital.
By that night, she had been diagnosed with necrotizing fasciitis and was undergoing surgery to remove an eight-inch swath of tissue across her torso and under her armpit.
The cases were separated by 2 months' time, and don't appear to have an obvious common source of the infection. Still, 2 cases of necrotizing fasciitis within a few months in people that close geographically is quite rare. According to the CDC, there are only ~700 cases of nec fash every year in the US.
I've written previously on the changing virulence of streptococci, and this is just another example of some of the damage invasive strep can do. What the article doesn't mention--and I've not seen any reports of this outbreak in the scientific literature yet, but they may be in progress--is if the strains are clones, or totally unrelated. They imply the latter, saying scientists don't have a reason to believe the infections are connected, but don't say what led them to that conclusion.
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Our unofficial motto is "Only in Boulder."
Do you know anything about antibiotic resistance in these outbreak strains? I imagine (and hope) that the hospitals conducting AST on these strains. Maybe that's why the article implied that the strains were different (i.e. different AST profiles)?
I notice that the article you link to states that, "In Canada, it is estimated that 90 to 200 cases of NF occur each year in all age groups ...". You would think that would translate, based on respective populations, to 900-2000 cases in the States, not ~700 as you report. That seems low. Or the Canadian numbers seem high.
Is there some particular reason for this apparent descrepancy I wonder? Differences in definition maybe?
I'm not aware of any resistance with strep pyogenes. We joke about how a light breeze kills the stuff. It's one of the few remaining diseases treatable with good ol penicillin. It obviously doesn't mean it can't cause serious infection though. Wimpy bugs can still kill and often do.
The problem with Necrotizing fasciitis and STSS (caused by GAS) is that even though they are easy bugs to treat, the disease is caused by a toxin (SpeA, also known as erythrogenic toxin or scarlet fever toxin). The toxin causes disease in very small amounts, and by the time it causes organ failure (as Tara said) the antibiotic doesn't do anything for the disease state. IVIG, debridement, and removal of necrotic tissue and huge swathes of the surrounding might save the persons life. It's pretty grim stuff. And S. aureus is starting to do it too...
http://hosted.ap.org/dynamic/stories/S/SUPPLEMENT_SETBACKS?SITE=NEYOR&S…
http://hosted.ap.org/dynamic/stories/D/DIET_ARTHRITIS?SITE=NEYOR&SECTIO…
Mike,
I've not been able to find much more info than was included in the article, so I don't know if they did susceptibility testing or not. That could be one way they tested them and decided they were different--I was thinking just of PFGE myself.
Dave,
The CDC has an even lower number for NF cases in the US: they say 600. Not sure about the discrepancy with the Canadian numbers--could be they're just too high, could be better surveillance. There's a group in Toronto that does a lot of work on invasive strep, so perhaps they have a good surveillance network that catches more cases than the US? Or maybe their national health care has better reporting than the US? Could be lots of reasons.
I don't know if the article mention it, but Dr. Cornell is a Nobel prize winner famous for his work on Bose-Einstein condensation. I had read about this story before. It is very scary.
"The problem with Necrotizing fasciitis and STSS (caused by GAS) is that even though they are easy bugs to treat, the disease is caused by a toxin (SpeA, also known as erythrogenic toxin or scarlet fever toxin)."
No chance of developing an antitoxin to bind to it?
Ha Ha! That is something my old lab worked on for years (in collaboration w/Wyeth, if I remember right) Full disclosure; I'd never get a dime from it even if it ever were made. The problem is not that neutralizing antibodies can't be made (they can) nor that toxoids can't be made (they were). A major problem has to do with the nature of the toxins. The toxins that cause these diseases are called Superantigens, because they cause an overstimulation of the immune system (T-cells, in this case). The overstimulation causes the immune system to attack the body. Immunizing against the SAgs is tricky, because they attack the very cells immunizations depend on (memory T-cells). Antitoxin is another possibility, but antitoxins (that is, serum containing neutralizing antibody) are not trivial to make, and probably would never be profitable against a relatively rare disease.
If you search medline for "Streptococcal Toxic Shock" or "GAS necrotizing fasciitis" you will, I'm fairly sure, come across a lot of papers (including fairly accessible reviews) on the subject. Several were written by my grad school advisor or fellow students (I worked on Staph, not Strep, but similar diseases)
I'm a general surgeon at a level I trauma center in Georgia (i.e. we get referrals for this disease). AFAIK nec fasc is not a CDC reportable illness and therefore the numbers are WAY underestimated. Off the cuff I know of 4-6 cases at this hospital in the last 6 months. No deaths yet.
Bill Bromberg
Hi BladeDoc,
Invasive group A strep infections (including NF) are listed here as reportable. I clicked back through the years (available here) and it's listed as early as they have online lists (2000). As far as how much it actually *is* reported, I dunno.
...as a former aspiring mph... i love this blogsite...
Is this negrotizing faciitis a new and spreading disease across the world,or has it always been around? The internet has lots of people getting it all over the country. I`m scared I could get too! Any news on research work in this area? Doctors need to be trained to diagnose this disease and not send people home with pain killers. There must be molecules this bacteria gives out through the body and blood, like toxins maybe. A fast way to diagnose it would be this way. I bet immune cells attach to it and pull it into the blood and lymph system. There must be some reason the immune cells don`t go out into the tissues and kill it. I don`t understand???
NF isn't new--the bacteria that cause it are of the same species that cause strep throat and other diseases. Doctors are indeed trained to recognize this, but some of the symptoms don't appear until it is almost too late, and serious measures must be undertaken to even allow the patient to survive (such as amputation or removal of much skin and muscle tissue). It can be a very fast-moving disease, and unfortunately, we don't understand all the reasons why this happens in some people but not in others.