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Retrospective case series: Necrotising fasciitis in 23 dogs
回顾性病例系列：23只犬的坏死性筋膜炎
作者：Laura L. Quilling| Catherine A. Outerbridge | Stephen D. White | Verena K. Affolter
翻译：赵群芳
Abstract
Background: Necrotising fasciitis (NF) is a rare, rapidly progressive subcutaneous bacterial infection. Few studies have characterised NF in dogs.
Hypothesis/objectives: To retrospectively describe clinical and laboratory findings, with treatments and outcomes, in dogs with NF.
Animals: Twenty-three client-owned dogs treated at a veterinary teaching hospital between 1998 and 2021.
Materials and Methods: Medical records and laboratory data from 23 dogs diagnosed with NF were reviewed.
Results: Male dogs were significantly over-represented (p =0.003). The most common presenting complaint was sudden lameness. Infection occurred in one or two limbs in 19 of 23 dogs, with right hindlimbs most often affected (13 of 23). Pitting oedema was evident in 14 of 23 dogs. Antibiotic and nonsteroidal anti-inflammatory drugs were administered before presentation in nine and 13 of 23 dogs, respectively. Common clinicopathological abnormalities included hypoalbuminemia, hyponatremia, elevated liver enzymes, elevated creatine kinase, increased bands and lymphopenia. Streptococcus canis was isolated from 18 of 23 dogs. Histopathological features included acute necrosis and severe neutrophilic inflammation. Fifteen dogs were euthanised or died, while surgical intervention led to survival in eight of 23 dogs.
Conclusions and clinical relevance: Dogs presenting for acute swelling of a limb with oedema should have the diagnosis of NF considered and early surgical intervention might increase survival.
摘要
背景：坏死性筋膜炎(NF)是一种罕见的、快速发展的皮下细菌感染。很少有研究描述犬NF的特征。
假设/目标：回顾性描述NF犬的临床和实验室结果、治疗和结局。
动物：1998年至2021年间，在兽医教学医院接受治疗的23只家养犬。
材料和方法：回顾23只确诊为NF的犬的医疗记录和实验室数据。
结果：雄性犬的比例显著过高 (p = 0.003)。最常见的主诉是突然跛行。23只犬中有19只发生单侧或双侧肢体感染，右后肢最常受累 (13/23)。23只犬中有14只出现明显的凹陷性水肿。23只犬中分别有9只和13只在就诊前给予抗生素和非甾体抗炎药。常见的临床病理异常包括低白蛋白血症、低钠血症、肝酶升高、肌酸激酶升高、杆状核中性粒细胞增多和淋巴细胞减少。从23只犬中的18只中分离出犬链球菌。组织病理学特征包括急性坏死和重度中性粒细胞炎症。15只犬被人道安乐死或死亡，而手术干预使23只犬中的8只存活。
结论和临床相关性：出现肢体急性肿胀伴水肿的犬应考虑NF的诊断，早期手术干预可能会增加存活率。
INTRODUCTION
介绍
Necrotising fasciitis (NF) is a rare, rapidly progressive bacterial infection within the subcutis, extending into fascia and occasionally skeletal muscle. In dogs, it is most commonly associated with B-haemolytic Streptococcus canis, a member of group G Streptococcus. Other bacteria reported in association with canine NF include Staphylococcus pseudintermedius, Staphylococcus aureus, Pasteurella multocida, Escherichia coli and Serratia marcescens.
坏死性筋膜炎 (NF) 是一种罕见的、快速发展的皮下组织内细菌感染，延伸至筋膜，偶尔累及骨骼肌。在犬中，最常与B型溶血性犬链球菌（G族链球菌的成员）相关。报告的与犬NF相关的其他细菌包括假中间型葡萄球菌、金黄色葡萄球菌、多杀巴斯德菌、大肠杆菌和粘质沙雷氏菌。
Dogs with NF typically present with severe pain and pyrexia with infection most commonly occurring on the neck or limbs. A history of minor trauma before the development of clinical signs of NF has been reported in some dogs.The most common cutaneous changes with canine NF are swelling and warmth of the affected area.Draining tracts, ulceration, erythema and necrosis also can occur. In humans, various systemic diseases leading to an immunocompromised state have been implicated as predisposing factors for NF.No such associations have been made in dogs to date.
NF犬通常表现为重度疼痛和发热伴感染，最常见于颈部或四肢。在一些犬中报告了NF临床症状出现前有过轻微创伤史。犬NF最常见的皮肤变化是受累区域肿胀和发热。也可发生引流道、溃疡、红斑和坏死。在人类中，导致免疫功能低下状态的各种全身性疾病被认为是NF的易感因素。迄今为止，在犬中未发现这样的相关性。
Disseminated intravascular coagulation (DIC), multiple system organ dysfunction syndrome (MODS) and shock ultimately result in death in 70%–80% of dogs with NF.This emphasises that rapid diagnosis and treatment are paramount for a chance of a successful outcome.
弥散性血管内凝血 (DIC)、多系统器官功能障碍综合征 (MODS) 和休克最终导致70%-80%的NF犬死亡。这强调了快速诊断和治疗对于获得成功结局的机会至关重要。
The purpose of this retrospective case series was to describe historical, clinical, diagnostic and laboratory findings combined with treatment and outcome information for dogs with NF.
本回顾性病例系列的目的是描述NF犬的病史、临床症状、诊断和实验室结果以及治疗和预后信息。
METHODS AND MATERIALS
材料与方法
Selection of cases
案例的选择
The computerised medical record system of the Veterinary Medical Teaching Hospital, University of California Davis (VMTH-UCD), was searched using the keywords ‘necrotizing fasciitis’, ‘necrotizing cellulitis’, ‘necrotizing panniculitis’ and ‘canine’, for cases that were treated by any service from 1998 to 2021. For inclusion, the following were required in the medical record or available for review: (i) antemortem skin biopsy or skin sample collected at necropsy showing severe acute neutrophilic cellulitis and fasciitis with marked necrosis; (ii) results from aerobic bacterial culture or cytological examination identifying bacteria; and (iii) clinical lesions characterised by peracute-to-acute inflammation and necrosis of skin and underlying tissues consistent with previous reports of canine NF.
使用关键词“坏死性筋膜炎”、“坏死性蜂窝织炎”、“坏死性脂膜炎”和“犬”，检索1998年至2021年间在兽医教学医院（加州大学戴维斯分校，VMTH-UCD）接受各种途径治疗的计算机化病历系统中的病例。对于入选标准，要求在病历中有以下被记录或可供审查的信息：(i) 死前皮肤活检或尸检时采集的皮肤样本显示重度急性中性粒细胞性蜂窝织炎和筋膜炎伴明显坏死；(ii) 需氧细菌培养或细胞学检查结果鉴定细菌；和 (iii) 以皮肤和皮下组织的超急性至急性炎症和坏死为特征的临床病变，与犬NF的既往报告一致。
Data analysis
数据分析
Medical records were reviewed for signalment, vital signs, cutaneous lesion descriptions, serum chemistry and haematological data, diagnostic imaging results, histopathological findings, previous drug administration, therapeutic interventions and outcome. Descriptive statistics were calculated when appropriate. Signalment details of affected dogs were compared with the hospital population using an exact chi-square test (Excel, v16.61.1, Microsoft).
审查病历中的特征、主要症状、皮肤病变描述、血清生化和血液学数据、影像诊断结果、组织病理学结果、用药史、治疗干预和结局。适当时计算描述性统计量。使用精确卡方检验 (Excel，v16.61.1，Microsoft) 将患犬的症状详情与医院种群进行比较。
For prior drug administration, all medications administered to the dogs one week before presentation were recorded. If a drug was administered within 24h of presentation, it was classified as administered after the development of NF.
对于用药史，记录就诊前一周给予犬的所有药物。如果药物在就诊后 24 h 内给药，则归类为NF发生后给药。
All histopathological samples for included dogs were reviewed by a board-certified anatomical pathologist (VKA) to verify correct diagnosis of NF and describe histopathological findings. The type of inflammation, presence of infectious organisms, necrosis, vasculitis and the location of these abnormalities were recorded.
由委员会认证的解剖病理学家 (VKA) 审查所有纳入犬的组织病理学样本，以验证NF 的正确诊断并描述组织病理学结果。记录炎症类型、是否存在感染性微生物、坏死、血管炎以及这些异常的位置。
RESULTS
结果
One hundred and three cases were found in the medical record system search with 23 meeting the inclusion criteria. Nine (39.1%) of these dogs were treated between 2017 and 2021.
在病历系统检索中发现103例病例，23例符合入选标准。这些犬中有9只 (39.1%) 在2017年至2021年间接受了治疗。
Signalment, clinical signs and culture results
特征、临床症状和培养结果
Demographic information, clinical signs, culture results and comorbidities are provided in Table 1. Male dogs were significantly over-represented, comprising 82.6% of the study population (p = 0.003). Intact animals were more common (p= 0.08). German shepherd dogs and their crosses were the most common breed, yet the sample size was not large enough for analysis. The most common presenting complaint was acute lameness in eight of 23 (34.7%), followed by sudden swelling of a limb in six of 23 (26.1%). A history of minor trauma was identified for five of 23 (21.7%) dogs.
群体统计学信息、临床症状、培养结果和并发症可见表1。雄性犬的比例显著过高，占研究总数的82.6%(p = 0.003)。未节育动物更常见 (p = 0.08)。德国牧羊犬及其杂交品种是最常见的品种，但样本量不足以进行分析。最常见的主诉是急性跛行 (8/23，34.7%)，其次是肢体突然肿胀 (6/23，26.1%)。23只犬中的5只 (21.7%) 确定有轻微创伤史。
The right-sided hindlimb was affected most commonly (13 of 23; 56% of dogs). The most common physical examination finding was pitting oedema, present in 14 of 23 (60.9%) dogs (Figure 1) followed by pain in nine of 23 dogs (39.1%). Concurrent diseases were present in five of 23 dogs (21%).
右后肢最常受累（13/23；56%的犬）。最常见的体格检查结果为凹陷性水肿，存在于23只犬中的14只 (60.9%)（图1），其次是23只犬中的9只 (39.1%) 疼痛。23只犬中有5只 (21%) 存在并发疾病。
Aerobic cultures were available for 22 dogs and anaerobic cultures for 20 dogs. The most frequently isolated organism was S. canis. Cytological evaluation of a lesional aspirate in one dog revealed chains of cocci consistent with Streptococcus sp. Monomicrobial cultures (14 of 22; 63.6% of dogs) were more common than polymicrobial cultures (eight of 22; 36.4% of dogs).
22只犬可获得需氧培养物，20只犬可获得厌氧培养物。最常分离出的微生物是犬链球菌。对一只犬的病灶抽吸物进行细胞学分析，发现与链球菌一致的球菌链。单微生物培养物（22只犬中的14只；63.6%的犬）比多微生物培养物（22只犬中的8只；36.4%的犬）更常见。
Disease duration, interventions and outcomes
疾病持续时间、干预措施和结局
Detailed information regarding duration of disease, interventions and outcomes is provided in Table 2.Surgery was performed in nine dogs and led to a successful outcome in eight, resulting in an overall survival rate of eight of 23 (34.8%) dogs. Of the remaining 15 dogs, five developed DIC or MODS before death or euthanasia. Eleven dogs were euthanised, either as a result of severity of presenting clinical signs (10 of 15 dogs) or postoperative progression of disease (one of 15 dogs) and four of 15 dogs died during hospitalisation or after discharge.
关于疾病持续时间、干预和结局的详细信息见表2。在9只犬中进行了手术，在8只犬中获得了成功结局，得到23只犬中8只 (34.8%) 的总生存率。在剩余的15只犬中，5只在死亡或人道安乐死前发生DIC或MODS。由于出现严重的临床症状不稳定（10/15只犬）或术后疾病进一步恶化（1/15只犬），人道安乐了11只犬，4/15只犬在住院期间或出院后死亡。
Medications
药物治疗
All medications are listed in Table 3. Before presentation, nine of 23 dogs (39%) were given antibiotics and 13 of 23 dogs (56.5%) received nonsteroidal antiinflammatory drugs (NSAIDs). The most commonly prescribed antibiotic before presentation was penicillin/sulbactam; six of seven (85.7%) of these dogs survived. Enrofloxacin was administered to four dogs before presentation, and one of four (25.0%) survived.During hospitalisation, five dogs received a combination of enrofloxacin and penicillin/sulbactam and one of five (20.0%) of these dogs survived. Six dogs received no antibiotics and were euthanised. Only dogs that were treated with antibiotics and underwent surgical intervention survived.
所有药物列于表3。就诊前，23只犬中的9只 (39%) 接受了抗生素，23只犬中的13只 (56.5%) 接受了非甾体抗炎药 (NSAID)。就诊前最常用的处方抗生素是青霉素/舒巴坦；其中6/7只 (85.7%) 犬存活。4只犬在就诊前给予恩诺沙星，4只中有1只 (25.0%) 存活。住院期间，5只犬接受了恩诺沙星和青霉素/舒巴坦联合治疗，其中1只 (20.0%) 犬存活。6只犬未接受抗生素治疗并实施安乐死。仅接受抗生素治疗并接受手术干预的犬存活。
Clinical pathological results
临床病理学结果
Serum biochemical and haematological data are presented in Table 4. Serum biochemical panels were available for review in 17 of 23 dogs (74%), and complete blood cell counts (CBC) were available for 11 of 23 dogs (48%).
血清生化和血液学数据见表4。17/23只犬 (74%) 的血清生化检查可供审查，11/23只犬 (48%) 的全血细胞计数 (CBC) 可供审查。
Diagnostic imaging
影像诊断
Eight dogs had diagnostic imaging performed before presentation, and six dogs had diagnostic imaging performed shortly after presentation. Radiographs were performed in 13 dogs, and a soft tissue swelling was identified in seven of 13 (53.8%) dogs. Ultrasound of the affected area was performed in seven dogs, and four of seven (57.1%) had hypoechoic regions containing hyperechoic material compatible with cellulitis.Computed tomography (CT) was performed on the affected limb in one dog, and findings were compatible with oedema/cellulitis.
8只犬在就诊前进行了诊断性成像，6只犬在就诊后不久进行了诊断性成像。对13只犬进行了 X 线检查，在13只犬中的7只 (53.8%) 中发现了软组织肿胀。对7只犬进行了患处超声检查，7只中有4只 (57.1%) 有含有与蜂窝织炎相容的强回声物质的低回声区。对一只犬的患肢进行计算机断层扫描 (CT)，结果与水肿/蜂窝织炎一致。
Histopathological results
组织病理学结果
Histopathological lesions involved the subcutis in 17 of 23 dogs (73.9%), fascia in 11 of 23 (47.8%), skeletal muscle in nine of 23 (39.1%) and skin in three of 23 (13.0%) dogs (Figure 2). Intralesional bacteria were observed in 11 of 23 dogs (47.8%).
组织病理学病变包括17/23只犬 (73.9%) 的皮下组织、11/23只犬 (47.8%) 的筋膜、9/23只犬 (39.1%) 的骨骼肌和3/23只犬 (13.0%) 的皮肤（图2）。在23只犬中的11只 (47.8%) 中观察到病灶内细菌。
A summary of the most common clinical, diagnostic and laboratory features documented in the affected dogs is listed in Table 5.
患犬中记录的最常见临床表现、诊断和实验室特征总结见表5。
DISCUSSION
讨论
Necrotising fasciitis is a devastating disease with high mortality. To the best of the authors' knowledge, this is the largest case series describing dogs with NF.Previous retrospective studies described a smaller number of dogs, and there also have been single case reports. Because nearly 40% of the dogs in this study were treated within the last five years (2016– 2021) of publication, this remains a concerning disease in veterinary medicine.
坏死性筋膜炎是一种破坏性疾病，死亡率很高。据作者所知，这是描述NF犬的最大病例系列。先前的回顾性研究描述了较少数量的犬，也有单个病例报告。由于本研究中近40%的犬在发表的最后5年内（2016-2021年）接受了治疗，这仍然是兽医中值得关注的疾病。
In humans, NF is classified as a polymicrobial (Type 1) or monomicrobial (Type 2) process. Canine NF more closely resembles Type 2 NF in humans, as monomicrobial infections were more frequently observed in the dogs of this study. Much like Type 2 human NF, comorbidities were not consistently associated with NF in dogs nor was there a predisposition for older individuals. While eight dogs in the present study were noted to have polymicrobial infections, some of the organisms that were isolated may have represented surface contaminants or commensal organisms.
在人医，NF分为多微生物过程（1型）或单微生物过程（2型）。犬NF更接近人类的2型NF，因为在本研究的犬中更常观察到单微生物感染。与2型人NF非常相似，在犬中NF的并发症并不一致，也无老年个体倾向。虽然本研究中的8只犬存在多种微生物感染，但分离的一些微生物可能是表面污染物或共生微生物。
Similar to other studies on canine NF, S.canis was the most commonly isolated bacterium. Streptococcus pyogenes is the most common causative agent of human NF. Streptococcus pyogenes and S. canis share only two virulence factors: protein M and streptolysin O. Canine NF has not been documented to result from a clonal expansion of more virulent strains of the organism, as is reported to occur in humans.
与犬NF的其他研究相似。犬链球菌是最常分离的细菌。化脓性链球菌是人类NF最常见的病原体。化脓性链球菌和犬链球菌仅有两种毒力因子：蛋白M和链球菌溶血素O。尚未证实犬NF是由毒力更强的微生物菌株克隆扩增所致，据报告在人类中也会发生。
The role of certain antibiotics in the pathogenesis of NF has not been fully characterised. Previous studies postulated that enrofloxacin may play a role in the development of canine NF. Enrofloxacin has been proposed as a risk factor for disease progression as a consequence of poor in vivo activity against streptococci.Furthermore, fluoroquinolones can cause bacteriophage lysis in Streptococcus via the SOS response, in which cell cycling is stopped in response to DNA damage and mutation, similar to Shiga toxin production in E.coli.Thus, enrofloxacin may cause the induction and spread of bacteriophages that encode the S.canis M-like Protein (scm) gene and via the SOS response result in the spread of these or similar virulence genes.
某些抗生素在 NF 发病机制中的作用尚未完全确定。先前的研究推测恩诺沙星可能在犬 NF 的发生中起作用。恩诺沙星被认为是疾病进展的危险因素，因为在体内抗链球菌的活性较差。此外，氟喹诺酮类药物可通过SOS反应在链球菌中引起噬菌体裂解，其中细胞循环因DNA损伤和突变而停止，类似于大肠杆菌中志贺毒素的产生。因此，恩诺沙星可能导致编码犬链球菌M样蛋白（scm）基因的噬菌体的诱导和传播，并通过SOS反应导致这些或类似毒力基因的传播。
Dogs in this retrospective that received no antibiotics or received solely enrofloxacin were less likely to survive compared with those dogs that received ampicillin/sulbactam. Based on human NF studies, the empiric use of clindamycin has been associated with a better outcome, which might be due to clindamycin inhibition of the expression of superantigen M-protein, which is known to play a major role in the pathophysiology of human NF. Antibiotic therapy typically is continued for four to six weeks in human NF cases. The current study cannot definitively determine if clindamycin improved outcome as only three dogs were administered the antibiotic and two of three survived. The only dog that received clindamycin and was euthanised did not have any surgical intervention.
本次回顾性研究中，与接受氨苄青霉素/舒巴坦的犬相比，未接受抗生素或仅接受恩诺沙星的犬存活率较低。基于人类NF研究，克林霉素的经验性使用与更好的预后相关，这可能是由于克林霉素抑制了超抗原M蛋白的表达，超抗原M在人类NF的病理生理学中起着重要作用。在人类NF病例中，抗生素治疗通常持续4至6周。目前的研究无法确定克林霉素是否能改善预后，因为只有三只犬服用了该抗生素，三只犬中有两只存活。唯一一只接受克林霉素并被安乐死的犬没有任何手术干预。
The administration of NSAIDs has been suspected to contribute to the development of NF in humans. Proposed mechanisms include masking of early clinical signs leading to delayed diagnosis and impairment of the immune system by inhibiting adherence, activation and phagocytic activity of granulocytes. It has been documented that nonselective NSAIDs may induce or accelerate NF in soft tissue infections with Group A Streptococcus species in mice. Over half of the dogs in this study had received NSAIDs at the time of presentation, probably reflecting the common initial presenting concern of pain and lameness. Five of the thirteen dogs that received NSAIDs survived and eight died. It is unknown if NSAIDs could have contributed to the development and/or progression of NF in any of these dogs and a potential association requires further study.
怀疑使用NSAID可促进人NF的发展。提出的机制包括通过抑制粒细胞的粘附、活化和吞噬活性掩盖早期临床症状，导致诊断延迟和免疫系统损伤。已有文献证实，非选择性 NSAID 可诱导或加速小鼠 A 组链球菌软组织感染中的NF。本研究中超过一半的犬在就诊时接受了NSAID，可能反映了最初常见的疼痛和跛行问题。接受 NSAID 的13只犬中有5只存活，8只死亡。尚不清楚 NSAID 是否可能促进任何这些犬发生和/或促进NF，且需要进一步研究潜在相关性。
In the current study, male dogs were obviously predisposed. In the initial reports of the disease, one study documented more males being affected with Streptococcal Toxic Shock Syndrome and NF, and it was not noted which sex was affected by which disease. Likewise, eight dogs with NF were identified in another study yet their sex was not reported. It is not clear if some of the same dogs were included in both of these reports. Other published case reports include both male and female dogs.Although not statistically significant, intact animals were affected more frequently in the current study. Previous studies have not analysed intact status.
在本研究中，雄性犬明显易感。在该疾病的初始报告中，一项研究记录了更多的雄性感染链球菌中毒性休克综合征和受到NF 的影响，但未记录哪种疾病影响哪种性别。同样，在另一项研究中确定了8只 NF 犬，但未报告其性别。尚不清楚这些报告中是否包括了一些相同的犬。其他已发表的病例报告包括雄性和雌性犬。虽然无统计学显著性，但在本研究中，未节育动物患病率更高。既往研究未分析未节育情况。
Dogs in the current study were most commonly affected on right-sided limbs. Previous reports indicate that limbs often are involved, yet the specific limb that was affected was not documented. The reason for right-sided limb involvement was not determined in this study.
本研究中的犬最常见右侧肢患病。既往报告表明，常见四肢患病，但未记录特定患病肢体。本研究未确定右侧肢体患病的原因。
A history of minor trauma has been noted in previous reports of NF in dogs.This was present in the records of a small number of dogs. Comorbidities or drug administration associated with concurrent diseases that may have produced a degree of immunosuppression also were present in only a small number of dogs. In this study, neither traumatic skin injury nor immunosuppression was consistently identified as factors associated with the development of NF.
在以前关于犬 NF 报告中，已观察到轻微创伤史。这存在于少数犬的记录中。与可能产生一定程度免疫抑制的并发疾病相关的合并症或给药也仅在少数犬中出现。在本研究中，创伤性皮肤损伤和免疫抑制均未被一致确定为 NF 发生的相关因素。
Diagnostic tests vary in their utility for diagnosing canine NF. Diagnostic imaging, particularly at an early stage, may not be a reliable tool with which to diagnose NF. Dogs that had radiographs performed in this study did not have any findings that could be considered pathognomonic for the disease. Ultrasound was reported to be useful for diagnosing NF in dogs and humans, via documenting cellulitis, thickened fascia and fluid accumulation along fascial planes. Gas tracking may be noted in soft tissue and fascia in humans, yet this was not observed in any of the dogs in this study.
诊断试验在诊断犬NF方面的实用性各不相同。影像诊断，特别是在早期阶段，可能不是诊断NF的可靠工具。在本研究中进行 X 线检查的犬无任何可视为疾病特异性的结果。据报道，超声可用于诊断犬和人类的NF，通过记录蜂窝织炎、筋膜增厚和沿筋膜平面的液体积聚。在人体软组织和筋膜中可能观察到气体踪影，但在本研究的任何犬中均未观察到。
Clinicopathological findings are often nonspecific in humans with NF and have not been described well in dogs with NF. There was variation in which biochemical tests were performed for various cases, and some common alterations were noted. The importance of these alterations is not known. Interestingly, hyponatremia is a common clinicopathological abnormality in humans with NF and was identified in a number of dogs with NF.
临床病理学结果在NF患者中通常无特异性，在 NF犬中未描述。对各种病例进行生化检查存在差异，并观察到一些常见变化。这些改变的重要性尚不清楚。有趣的是，低钠血症是NF患者常见的临床病理学异常，并在许多NF犬中发现。
Histopathological features of canine NF in the current study are consistent with histopathological changes observed in previous reports of canine NF as well as NF in humans and mice. After reviewing the medical records and available histopathological samples, it was evident that for many cases that did not meet our inclusion criteria, the term ‘necrotizing fasciitis’ reflected a pathological morphological diagnosis and not NF, the actual clinical entity or disease. It is important to combine clinical signs and history in addition to histopathological findings in order to make a definitive diagnosis.
本研究中犬 NF 的组织病理学特征与先前报告的犬 NF 以及人和小鼠 NF 中观察到的组织病理学变化一致。在审查病历和可用的组织病理学样本后，很明显许多病例不符合我们入选标准，术语“坏死性筋膜炎”反映了病理学形态学诊断，而不是NF的实际的临床实体或疾病。除组织病理学表现外，结合临床症状和病史，对作出明确诊断具有重要意义。
There is no treatment consensus for canine NF.Previously reported surgical interventions include debridement of all necrotic tissue and in some cases additional surgical procedures such as amputation, fusion podoplasty and tissue resection with reconstruction.
犬 NF 尚无治疗共识。之前报告的手术干预包括清除所有坏死组织，在某些病例中还包括额外的外科手术，如截肢、足部融合成形术和组织切除与重建。
Several reports suggest that negative pressure wound therapy (NPWT) following debridement may improve prognosis and decrease morbidity in dogs. In the current study, the dogs that survived received systemic antibiotics and underwent amputation or NPWT following debridement of the affected tissue.
一些报告表明，清创术后负压伤口治疗（NPWT）可改善犬的预后并降低发病率。在目前的研究中，幸存的犬接受了全身抗生素治疗，并在对受影响组织进行清创术后接受了截肢或NPWT治疗。
Limitations of this study are its retrospective nature and the small number of dogs included. Examinations and types of diagnostic tests were performed by multiple clinicians, resulting in variation in the recorded findings and descriptions of cutaneous lesions. Owing to the small sample size, it was not possible to identify breed predisposition.
本研究的局限性在于其回顾性性质和纳入的犬数量较少。由多名临床医生进行检查和诊断试验类型，导致记录的结果和皮肤病变描述存在差异。由于样本量较小，无法确定品种倾向。
The early clinical features and the clinicopathological changes associated with NF in humans are not pathognomonic. This presents challenges for making an early diagnosis, which is critical for positive outcomes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) has been established to aid in the rapid diagnosis of NF. In this scoring system, numeric values are assigned for laboratory values that often are abnormal in human cases of NF. Utilising this objective scoring system allows physicians to more accurately and quickly pursue additional diagnostics and surgical intervention. No such scoring system exists in veterinary medicine. Since the initial description of canine NF in 1996, few advances in diagnosis and treatment have been made. A scoring system similar to LRINEC in humans could be beneficial for improving outcomes for dogs with NF. The common clinical features identified in this study could serve as a starting point for such a scoring system.
人类NF的早期临床特征和相关的的临床病理变化并非特征性的。这给早期诊断带来了挑战，而早期诊断对于积极的结果至关重要。已建立坏死性筋膜炎实验室风险指标（LRINEC），以帮助快速诊断NF。在该评分系统中，为人类NF病例中通常异常的实验室值分配数值。利用这种客观评分系统，医生可以更准确、更快地追求额外的诊断和手术干预。兽药中不存在此类评分系统。自1996年首次描述犬NF以来，诊断和治疗方面的进展很少。类似于人类LRINEC的评分系统可能有助于改善患有NF的犬的预后。本研究中确定的常见临床特征可作为此类评分系统的起点。
CONCLUSION
结论
Necrotising fasciitis is an uncommon yet devastating disease in dogs. Careful evaluation for NF should be performed in all febrile dogs with a history of rapid onset painful oedema, particularly in the limbs. This evaluation should include cytological examination and aerobic bacterial culture, along with CBC and serum biochemistry. The identification of S. canis on aerobic culture or of chains of cocci consistent with Streptococcus sp. should prompt consideration of NF as a differential diagnosis, regardless of the dog's age or immune system status. Empirical administration of ampicillin/sulbactam and clindamycin is recommended. Enrofloxacin and perhaps NSAIDs should be avoided. Rapid surgical intervention is recommended for successful management of this often-fatal infection.
坏死性筋膜炎是犬中一种不常见但具有破坏性的疾病。对所有有快速发作疼痛性水肿病史的发热患犬，尤其是四肢，应仔细评估NF。该评估应包括细胞学检查和需氧细菌培养，以及 CBC 和血清生化。无论犬的年龄或免疫系统状况如何，在需氧培养物上鉴定犬链球菌或与链球菌属一致的球菌链时，都应考虑将NF作为鉴别诊断。建议使用氨苄青霉素/舒巴坦和克林霉素。应该避免使用恩诺沙星和非甾体抗炎药。建议进行快速手术干预，以成功治疗这种经常致命的感染。
表1 病患的详细信息
|
基础信息（体重/kg） |
位置 |
培养结果 |
皮肤检查 |
合并症 |
1 |
12岁已去势雄性澳大利亚牧羊犬（30.6） |
右前肢 |
犬链球菌 |
凹陷性水肿 |
嗜铬细胞瘤，T3-尾侧脊髓病 |
2 |
5岁已去势雄性toller寻回犬（20.6） |
右后肢 |
犬链球菌，变形杆菌 |
瘘道 |
免疫介导的多发性关节炎 |
3 |
5月龄雄性拳狮犬（一） |
右后肢 |
犬链球菌 |
凹陷性水肿，明显疼痛，发热 |
无 |
4 |
8岁雄性爱尔兰猎犬（90.0） |
右后肢 |
犬链球菌 |
凹陷性水肿，瘘道 |
无 |
5 |
6岁已去势雄性比特犬（22.7） |
左后肢 |
犬链球菌 |
肿胀，明显疼痛 |
无 |
6 |
9岁已去势雄性德国牧羊犬（54.5） |
右后肢 |
犬链球菌 |
凹陷性水肿，明显疼痛，发热 |
过敏性皮肤病、肛周瘘 |
7 |
1岁雄性中国沙皮犬（27） |
双侧后肢 |
犬链球菌 |
肿胀、瘀斑、水疱、发热 |
家族性沙皮热 |
8 |
5岁已去势雄性混血犬（54） |
左前肢 |
犬链球菌 |
肿胀、瘘道、明显疼痛 |
骨肉瘤 |
9 |
4岁已绝育雌性迷你杜宾犬（3.3） |
胸部，侧面 |
犬链球菌 |
凹陷性水肿，淤斑 |
无 |
10 |
2岁已去势雄性混血犬（42.9） |
腰部下方 |
犬链球菌 |
明显疼痛，发热 |
无 |
11 |
不知年龄已去势雄性巴哥犬（7.3） |
右后肢 |
犬链球菌，产气荚膜梭菌，厌氧链球菌 |
皱褶磨损，明显疼痛 |
无 |
12 |
7月龄雌性混血犬（25） |
右后肢 |
犬链球菌 |
凹陷性水肿，瘘道、发热 |
无 |
13 |
5月龄雌性大丹犬（27.1） |
右后肢 |
犬链球菌 |
凹陷性水肿，明显疼痛、发热 |
无 |
14 |
4岁雄性英格兰雪达犬（17.2） |
左前肢 |
犬链球菌，粪产碱杆菌 |
凹陷性水肿，发热 |
无 |
15 |
8岁已去势雄性德国牧羊犬（42.5） |
双侧后肢 |
犬链球菌，大肠杆菌，粪肠球菌 |
肿胀 |
脑干脑膜瘤，退行性椎间盘疾病 |
16 |
10岁已去势雄性混血犬（未知） |
右前肢 |
未进行，前肢受累组织中存在链状球菌 |
发红、瘀斑、发热 |
癫痫 |
17 |
7岁已去势雄性金毛寻回犬（48） |
颈部 |
巴氏杆菌属，绿色气球菌 |
凹陷性水肿、瘀斑、发热 |
甲状腺 C 细胞癌 |
18 |
8岁已去势雄性金毛寻回犬（29） |
尾部 |
犬链球菌 |
凹陷性水肿、瘀斑、明显疼痛、发热 |
无 |
19 |
8岁已去势雄性中国沙皮犬（24.3） |
双侧后肢 |
犬链球菌， 中间葡萄球菌 |
溃疡、肿胀、坏死 |
无 |
20 |
2岁雄性维兹拉犬（24） |
右后肢 |
非溶血性大肠杆菌 |
凹陷性水肿、瘀斑 |
无 |
21 |
2岁雄性英国斗牛犬（20.9） |
右后肢 |
伪中间性葡萄球菌，芽孢杆菌属 |
红斑、凹陷性水肿、坏死、发热 |
无 |
22 |
2岁已去势雄性马斯提夫犬（93.9） |
右前肢 |
犬链球菌， 伪中间性葡萄球菌 |
红斑、凹陷性水肿、瘀斑、坏死 |
无 |
23 |
4岁已绝育雌性混血犬（31.0） |
右后肢、腹股沟 |
伪中间性葡萄球菌 |
红斑、凹陷性水肿、瘀斑、明显疼痛 |
耳血肿 |
 FIGURE 1 Clinical images of dogs with necrotising fasciitis. (a) Dog 22 at presentation. There is marked pitting oedema and erythema with multifocal necrosis of the distal right forelimb. (b) Dog 22 following surgical debridement of the affected tissue. (c) Dog 22 six days after surgical debridement and wound vacuum therapy. There is granulation tissue forming. (d) Dog 20 at presentation. There is marked pitting oedema, ecchymosis, erythema and necrosis of the right hindlimb. Surgical debridement was performed; the dog was euthanised as a consequence of disease progression.
图1 坏死性筋膜炎犬的临床图像。(a) 患犬22在就诊时。右前肢远端有明显的凹陷性水肿和红斑伴多灶性坏死。(b) 患犬22患病组织手术清创后。(c) 患犬22手术清创和伤口真空治疗后第6天。有肉芽组织形成。(d) 患犬20就诊时。右后肢有明显的凹陷性水肿、瘀斑、红斑和坏死。进行了手术清创；由于疾病进展，对犬实施了安乐死。
TABLE 2 Detailed patient information regarding duration of necrotising fasciitis, interventions and outcomes
表2 详细第患者信息关于坏死性筋膜炎持续时间、干预措施和预后
|
就诊前临床症状的持续时间 |
住院时间 |
住院到进行治疗间的时间 |
治疗 |
预后 |
1 |
＜24小时 |
7天 |
抗生素：<24小时 手术：2天 |
切开和引流，JP引流管 抗生素（静脉注射，口服） |
存活 |
2 |
5天 |
＜24小时 |
未知 |
无 |
安乐死 |
3 |
8天 |
＜24小时 |
未知 |
无 |
安乐死 |
4 |
1天 |
2天 |
＜24小时 |
抗生素（静脉注射） |
安乐死 |
5 |
3天 |
2天 |
未知 |
无 |
安乐死 |
6 |
1天 |
5天 |
4天 |
抗生素（静脉注射） |
安乐死 |
7 |
＜24小时 |
3天 |
3天 |
抗生素（静脉注射） |
死亡 |
8 |
2天 |
＜24小时 |
未知 |
无 |
安乐死 |
9 |
1天 |
3天 |
1天 |
抗生素（静脉注射） |
死亡 |
10 |
4天 |
2天 |
未知 |
无 |
安乐死 |
11 |
未知 |
＜24小时 |
未知 |
无 |
安乐死 |
12 |
3天 |
5天 |
抗生素：<24小时 手术：1天 |
清创术，JP引流管放置 抗生素（静脉注射、口服） |
存活 |
13 |
＜24小时 |
6天 |
抗生素：<24小时 手术：<24小时 |
清创术，JP引流管放置 抗生素（静脉注射、口服） |
存活 |
14 |
＜24小时 |
1天 |
<24小时 |
抗生素（静脉注射） |
死亡 |
15 |
3天 |
＜24小时 |
<24小时 |
抗生素（静脉注射） |
安乐死 |
16 |
4天 |
＜24小时 |
未知 |
无 |
安乐死 |
17 |
1天 |
3天 |
<24小时 |
抗生素（静脉注射） |
死亡 |
18 |
＜24小时 |
3天 |
抗生素：<24小时 手术：<24小时 |
截肢术， 抗生素（静脉注射） |
存活 |
19 |
5天 |
4天 |
抗生素：1天 手术：1天 |
清除术， 抗生素 |
存活 |
20 |
3天 |
6天 |
抗生素：<24小时 手术：1天 安乐死：13天 |
清创术， 抗生素（静脉注射、口服） |
安乐死 |
21 |
1天 |
5天 |
抗生素：<24小时 手术：2天 |
截肢术， 抗生素（静脉注射、口服） |
存活 |
22 |
3天 |
19天 |
抗生素：1天 手术：3天 负压伤口治疗：7天 |
清创术，负压伤口治疗， 抗生素（静脉注射、口服） |
存活 |
23 |
＜24小时 |
13天 |
抗生素：1天 手术：1天 负压伤口治疗：2天 JP引流管：8天 |
清创术，负压伤口治疗，JP引流管 抗生素（静脉注射、口服 |
存活 |
Abbreviations: i.v., intravascular; JP, Jackson-Pratt drain; NA, not applicable; NPWT, negative pressure wound therapy; p.o., per os.
缩写:i.v.，血管内;JP, Jackson-Pratt引流;NA，不适用;NPWT，负压伤口治疗;P.o，口服。
TABLE 3 Drugs administered to dogs before diagnosis of necrotising fasciitis
表3 坏死性筋膜炎诊断前给予犬的药物
|
就诊前使用的抗生素 |
就诊后使用的抗生素 |
就诊前使用非甾体抗炎药 |
就诊后使用非甾体抗炎药 |
就诊前使用的其他药物 |
就诊后使用的其他药物 |
1 |
氨苄西林/舒巴坦 |
无 |
卡洛芬 |
无 |
加巴喷丁 |
氢吗啡酮，补液 |
2 |
无 |
无 |
无 |
无 |
泼尼松、环孢菌素 |
无 |
3 |
阿莫西林 |
无 |
不明成分的非甾体抗炎药 |
无 |
无 |
|
4 |
无 |
恩诺沙星、氨苄西林 |
德拉昔布 |
无 |
曲马多 |
氢吗啡酮，补液 |
5 |
无 |
无 |
卡洛芬 |
无 |
加巴喷丁 |
无 |
6 |
克林霉素、恩诺沙星、替卡西林/克拉维酸 |
无 |
无 |
无 |
硫唑嘌呤、泼尼松、酮康唑 |
无 |
7 |
无 |
多西环素、恩诺沙星、氨苄西林 |
无 |
卡洛芬、阿司匹林 |
无 |
法莫替丁，硫糖铝 |
8 |
无 |
无 |
德拉昔布 |
无 |
曲马多 |
无 |
9 |
无 |
恩诺沙星、替卡西林/克拉维酸、青霉素G |
无 |
无 |
脂肪酸、维生素E |
葡萄糖、补液、血浆输注、肝素 |
10 |
无 |
无 |
美洛昔康 |
无 |
无 |
补液，氢吗啡酮 |
11 |
无 |
无 |
无 |
无 |
无 |
补液，烯啶虫胺 |
12 |
头孢他啶、氨苄西林/舒巴坦 |
恩诺沙星 |
卡洛芬 |
无 |
氢吗啡酮、芬太尼、补液 |
丁丙诺啡 |
13 |
无 |
氨苄西林/舒巴坦 |
美洛昔康 |
卡洛芬 |
加巴喷丁、氢吗啡酮 |
右旋美托咪定、补液、曲唑酮 |
14 |
无 |
恩诺沙星、氨苄西林、甲硝唑、氨苄西林/舒巴坦 |
无 |
无 |
泼尼松 |
雷尼替丁、补液、维生素K、氢吗啡酮 |
15 |
头孢氨苄 |
无 |
非罗考昔 |
无 |
曲马多 |
补液 |
16 |
无 |
无 |
无 |
无 |
无 |
无 |
17 |
无 |
替卡西林/克拉维酸、恩诺沙星 |
无 |
无 |
无 |
葡萄糖、氢吗啡酮、补液 |
18 |
无 |
头孢唑啉 |
无 |
无 |
无 |
补液 |
19 |
恩诺沙星（住院时停止） |
氨苄西林、阿莫西林/克拉维酸 |
布洛芬 |
德拉昔布 |
无 |
补液、吗啡 |
20 |
阿莫西林/克拉维酸 |
无 |
不明成分的非甾体抗炎药 |
无 |
芬太尼、曲马多 |
补液，泮托拉唑 |
21 |
马坡沙星、阿莫西林/克拉维酸 |
克林霉素 |
卡洛芬 |
无 |
无 |
氢吗啡酮、马罗匹坦 |
22 |
恩诺沙星（住院时停止） |
氨苄西林/舒巴坦 |
非罗考昔 |
无 |
苯海拉明、曲马多 |
补液 |
23 |
无 |
氨苄西林/舒巴坦、克林霉素 |
无 |
无 |
泼尼松 |
氢吗啡酮、苯海拉明、补液 |
TABLE 4 Clinicopathological abnormalities in dogs with necrotising fasciitis
表4 坏死性筋膜炎犬的临床病理学异常
异常 |
受影响的患者 |
中值 |
范围 |
参考值 |
低钠血症(mmol/L) |
9/17 |
143mmol/L |
128–158 |
143–151 |
碳酸氢盐下降(mmol/L) |
10/17 |
16.0 |
10–25 |
20–26 |
低钙血症(mmol/L) |
总钙：8/12 游离钙：2/12 |
总钙：9.5 游离钙：1.2 |
总钙：8–10.7 游离钙：1.1–1.45 |
总钙：9.6–11.2 游离钙：1.2–1.5 |
低白蛋白血症(g/dL) |
11/12 |
2.6 |
1.9–3.8 |
3.4–4.3 |
肝酶升高 -ALP/ALT/AST (IU/L) |
11/12 |
ALP: 431 ALT: 64.5 AST: 59 |
ALP: 89–1579 ALT: 22–338 AST: 26–145 |
ALP: 14–91 ALT: 21–72 AST: 20–49 |
肌酸激酶升高(IU/L) |
5/7 |
430.0 |
55–257 |
91–1006 |
杆状核细胞增多（/μL） |
10/11 |
1187.5 |
87–4855 |
>0 |
淋巴细胞减少（/μL） |
8/11 |
653 |
102–5252 |
1000-4000 |
 FIGURE 2 Histopathological images showing abnormalities in skin biopsy samples from dogs with necrotising fasciitis. (a) Severe diffuse cellulitis extending into superficial fascia and focal extension into deep dermis. Haematoxylin & eosin, ×20, Dog 1. (b) Degenerate inflammatory cells are embedded in fibrin and necrosis separating and dissecting collagen bundles. H&E, ×200, Dog 2; (c) Admixed with degenerate neutrophils with pyknotic nuclei are a myriad of cocci. H&E, ×600, Dog 2; (d) Numerous gram-positive cocci (dark blue) arranged in chains admixed with degenerate neutrophils. Gram stain, ×600, Dog 2.
图2 显示坏死性筋膜炎犬皮肤活检样本异常的组织病理学图像。(a) 重度弥漫性蜂窝织炎延伸至浅筋膜，局灶性延伸至真皮深层。苏木精和伊红，×20，犬1。(b) 退化的炎性细胞嵌入纤维蛋白和坏死组织中，分离和剖解胶原束。H&E，×200，犬2；(c) 与核固缩的退化中性粒细胞混合的是无数的球菌。。H&E，×600，犬2；(d) 许多革兰氏阳性球菌（深蓝色）呈链状排列，混合着退化的中性粒细胞。革兰氏染色，×600，犬2。
TABLE 5 Most common presenting complaints, physical examination findings and clinicopathological abnormalities in 23 dogs with necrotising fasciitis
表5 23只坏死性筋膜炎犬的最常见主诉、体格检查结果和临床病理学异常
最常见的临床特征 |
温度≤39.7摄氏度 |
心动过速≥140次/分 |
凹陷性水肿±肿胀 |
明显疼痛 |
瘀斑 |
肢体受累 |
急性跛行 |
发展迅速（<72小时） |
NSAID的使用 |
低钠血症 |
碳酸氢盐下降 |
低白蛋白血症 |
肝酶升高 |
肌酸激酶升高 |
杆状核细胞增多 |
淋巴细胞减少 |
X光显示软组织肿胀 |
| 
|Archiver|手机版|小黑屋|宠医帮
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发表于 2022-11-24 13:43:23
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