糖尿病足坏死性筋膜炎病理生理机制及诊治

doi:10.3877/cma.j.issn.1673-9450.2020.05.012

糖尿病足坏死性筋膜炎起病急、发展快，可迅速进展为皮肤、皮下脂肪组织、浅筋膜及深筋膜的广泛坏死，其截肢(趾)风险高，病死率高。糖尿病足坏死性筋膜炎病理生理机制包括糖尿病周围神经病变、糖尿病周围血管病变、感染等，但具体机制复杂，尚未完全明确，其治疗包括局部清创、抗感染等，但多数糖尿病足坏死性筋膜炎早期易误诊和漏诊，应引起高度重视。本文就糖尿病足坏死性筋膜炎病理生理机制、诊断及治疗进行综述，为提高对糖尿病足坏死性筋膜炎的认识和治疗提供理论和临床依据。

关键词: 糖尿病足, 筋膜炎, 坏死性, 病理生理机制, 诊治

The necrotizing fasciitis of diabetic foot, rapid onset and development, can rapidly progress to extensive necrosis of the skin, subcutaneous adipose tissue, superficial fascia and deep fascia, with a high risk of amputation and mortality. The pathophysiology of necrotizing fasciitis of diabetic foot is associated with peripheral neuropathy, peripheral arterial disease, infection and so on. However, the pathophysiology of necrotizing fasciitis of diabetic foot is complicated and remains unclear. The clinical treatment in necrotizing fasciitis of diabetic foot involves wound debridement, anti-infection and so on. However, most patients in early stages of necrotizing fasciitis of diabetic foot are easily misdiagnosed, to which should be paid great attention. The purpose of the present article is to review and discuss the pathophysiology, diagnose and treatment in necrotizing fasciitis of diabetic foot, in order to providing the theory basis for it.

Key words: Diabetic foot, Fasciitis, necrotizing, Pathophysiology, Diagnose and treatment

表1 LRINEC评分

项目		分值(分)
C反应蛋白(mg/L)
	<150	0
	≥150	4
白细胞计数(10⁹/L)
	<15	0
	15～25	1
	>25	2
血红蛋白(g/L)
	>135	0
	110～135	1
	<110	2
血钠(mmol/L)
	≥135	0
	<135	2
血肌酐(umol/L)
	≤141	0
	>141	2
血糖(mmol/L)
	≤10	0
	>10	1

表1 LRINEC评分

项目		分值(分)
C反应蛋白(mg/L)
	<150	0
	≥150	4
白细胞计数(10⁹/L)
	<15	0
	15～25	1
	>25	2
血红蛋白(g/L)
	>135	0
	110～135	1
	<110	2
血钠(mmol/L)
	≥135	0
	<135	2
血肌酐(umol/L)
	≤141	0
	>141	2
血糖(mmol/L)
	≤10	0
	>10	1

[1]	Wilson B. Necrotizing fasciitis[J]. Am Surg, 1952, 18(4): 416-431.
[2]	Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections[J]. Infect Dis Clin North Am, 2017, 31(3): 497-511.
[3]	Harbrecht BG, Nash NA. Necrotizing Soft Tissue Infections: A Review[J]. Surg Infect (Larchmt), 2016, 17(5): 503-509.
[4]	Iacopi E, Coppelli A, Goretti C, et al. Necrotizing Fasciitis and The Diabetic Foot[J]. Int J Low Extrem Wounds, 2015, 14(4): 316-327.
[5]	Ahn J, Raspovic KM, Liu GT, et al. Lower Extremity Necrotizing Fasciitis in Diabetic and Nondiabetic Patients: Mortality and Amputation[J]. Int J Low Extrem Wounds, 2019, 18(2): 114-121.
[6]	Fernando SM, Tran A, Cheng W, et al. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis[J]. Ann Surg, 2019, 269(1): 58-65.
[7]	Khamnuan P, Chongruksut W, Jearwattanakanok K, et al. Necrotizing fasciitis: epidemiology and clinical predictors for amputation[J]. Int J Gen Med, 2015, 14(8): 195-202.
[8]	Goh T, Goh LG, Ang CH, et al. Early diagnosis of necrotizing fasciitis[J]. Br J Surg, 2014, 101(1): e119-125.
[9]	Zhang P, Lu J, Jing Y, et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis (dagger)[J]. Ann Med, 2017, 49(2): 106-116.
[10]	Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence[J]. N Engl J Med, 2017, 376(24): 2367-2375.
[11]	Horn DL, Shen J, Roberts E, et al. Predictors of mortality, limb loss, and discharge disposition at admission among patients with necrotizing skin and soft tissue infections[J]. J Trauma Acute Care Surg, 2020, 89(1): 186-191.
[12]	Audureau E, Hua C, de Prost N, et al. Mortality of necrotizing fasciitis: relative influence of individual and hospital-level factors, a nationwide multilevel study, France, 2007-12[J]. Br J Dermatol, 2017, 177(6): 1575-1582.
[13]	Jabbour G, El-Menyar A, Peralta R, et al. Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital[J]. World J Emerg Surg, 2016, 11(40): 1-10.
[14]	Chen IW, Yang HM, Chiu CH, et al. Clinical Characteristics and Risk Factor Analysis for Lower-Extremity Amputations in Diabetic Patients With Foot Ulcer Complicated by Necrotizing Fasciitis[J]. Medicine (Baltimore), 2015, 94(44): e1957.
[15]	Volmer-Thole M, Lobmann R. Neuropathy and Diabetic Foot Syndrome[J]. Int J Mol Sci, 2016, 17(6): 917.
[16]	Bandyk DF. The diabetic foot: Pathophysiology, evaluation, and treatment[J]. Semin Vasc Surg, 2018, 31(2/4): 43-48.
[17]	Sage RA, Webster JK, Fisher SG. Outpatient care and morbidity reduction in diabetic foot ulcers associated with chronic pressure callus[J]. J Am Podiatr Med Assoc, 2001, 91(6): 275-279.
[18]	Markakis K, Bowling FL, Boulton AJ. The diabetic foot in 2015: an overview[J]. Diabetes Metab Res Rev, 2016, 32 (Suppl 1): 169-178.
[19]	Arosi I, Hiner G, Rajbhandari S. Pathogenesis and Treatment of Callus in the Diabetic Foot[J]. Curr Diabetes Rev, 2016, 12(3): 179-183.
[20]	Schreml S, Szeimies RM, Prantl L, et al. Oxygen in acute and chronic wound healing[J]. Br J Dermatol, 2010, 163(2): 257-268.
[21]	Catrina SB, Zheng X. Disturbed hypoxic responses as a pathogenic mechanism of diabetic foot ulcers[J]. Diabetes Metab Res Rev, 2016, 32 (Suppl 1): 179-185.
[22]	Hoenig MR, Bianchi C, Sellke FW. Hypoxia inducible factor-1 alpha, endothelial progenitor cells, monocytes, cardiovascular risk, wound healing, cobalt and hydralazine: a unifying hypothesis[J]. Curr Drug Targets, 2008, 9(5): 422-435.
[23]	Wang H, Feng Y, Jin X, et al. Augmentation of hypoxia-inducible factor-1-alpha in reinfused blood cells enhances diabetic ischemic wound closure in mice[J]. Oncotarget, 2017, 8(69): 114251-114258.
[24]	Krishnaswamy VR, Mintz D, Sagi I. Matrix metalloproteinases: The sculptors of chronic cutaneous wounds[J]. Biochim Biophys Acta Mol Cell Res, 2017, 1864(11 Pt B): 2220-2227.
[25]	Davis FM, Kimball A, Boniakowski A, et al. Dysfunctional Wound Healing in Diabetic Foot Ulcers: New Crossroads[J]. Curr Diab Rep, 2018, 18(1): 2.
[26]	Dunnill C, Patton T, Brennan J, et al. Reactive oxygen species (ROS) and wound healing: the functional role of ROS and emerging ROS-modulating technologies for augmentation of the healing process[J]. Int Wound J, 2017, 14(1): 89-96.
[27]	Morgan MS. Diagnosis and management of necrotising fasciitis: a multiparametric approach[J]. J Hosp Infect, 2010, 75(4): 249-257.
[28]	Grigoropoulou P, Eleftheriadou I, Jude EB, et al. Diabetic Foot Infections: an Update in Diagnosis and Management[J]. Curr Diab Rep, 2017, 17(1): 3.
[29]	李艳艳，刚晓坤，肖显超，等. 糖尿病足合并感染的病原菌分布特点及药敏变迁的临床观察[J]. 中国糖尿病杂志，2019, 27(1): 16-21.
[30]	Eleftheriadou I, Tentolouris N, Argiana V, et al. Methicillin-resistant Staphylococcus aureus in diabetic foot infections[J]. Drugs, 2010, 70(14): 1785-1797.
[31]	Kwon KT, Armstrong DG. Microbiology and Antimicrobial Therapy for Diabetic Foot Infections[J]. Infect Chemother, 2018, 50(1): 11-20.
[32]	Clinton A, Carter T. Chronic Wound Biofilms: Pathogenesis and Potential Therapies[J]. Lab Med, 2015, 46(4): 277-284.
[33]	Gompelman M, van Asten SA, Peters EJ. Update on the Role of Infection and Biofilms in Wound Healing: Pathophysiology and Treatment[J]. Plast Reconstr Surg, 2016, 138(3 Suppl): 61S-70S.
[34]	Mottola C, Mendes JJ, Cristino JM, et al. Polymicrobial biofilms by diabetic foot clinical isolates[J]. Folia Microbiol (Praha), 2016, 61(1): 35-43.
[35]	Banu A, Noorul Hassan MM, Rajkumar J, et al. Spectrum of bacteria associated with diabetic foot ulcer and biofilm formation: A prospective study[J]. Australas Med J, 2015, 8(9): 280-285.
[36]	Scherr TD, Hanke ML, Huang O, et al. Staphylococcus aureus Biofilms Induce Macrophage Dysfunction Through Leukocidin AB and Alpha-Toxin[J]. mBio, 2015, 6(4): e01021-15.
[37]	Ramirez T, Shrestha A, Kishen A. Inflammatory potential of monospecies biofilm matrix components[J]. Int Endod J, 2019, 52(7): 1020-1027.
[38]	Ghotaslou R, Memar MY, Alizadeh N. Classification, microbiology and treatment of diabetic foot infections[J]. J Wound Care, 2018, 27(7): 434-441.
[39]	Tessier JM, Sanders J, Sartelli M, et al. Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics[J]. Surg Infect (Larchmt), 2020, 21(2): 81-93.
[40]	Wynn M, Freeman S. The efficacy of negative pressure wound therapy for diabetic foot ulcers: A systematised review[J]. J Tissue Viability, 2019, 28(3): 152-160.

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The pathophysiology and treatment in necrotizing fasciitis of diabetic foot

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The pathophysiology and treatment in necrotizing fasciitis of diabetic foot