flesh-eating bacteria is on the rise in canada and 'scaring the living daylights' out of er doctors
strep a, normally a relatively harmless bacterium that causes throat infections, can lead to amputations and death if it enters a wound
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irish actor barry keoghan revealed in a gq cover story last year that he nearly died from necrotizing fasciitis.
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rapidly spreading, harrowing and potentially lethal, a necrotizing soft tissue infection — so-called flesh-eating disease — “scares the living daylights” out of doctors, as several shared on a canadian medical association journal podcast that dropped this week.
the infections are often caused by invasive group a streptococcus, a bacterium that is increasing in canada and globally, for reasons that remain unclear.
“we’ve all had some tough cases,” dr. stephanie mason said in an interview with national post.
a general and burn surgeon at toronto’s sunnybrook hospital, mason recently lost a patient she fought hard to save, a woman in her 30s who died after a delayed diagnosis. “we didn’t get to her soon enough,” mason said, a tragedy that wasn’t the fault of any one person, but rather a system that didn’t mobilize as fast as it needed to.
“nec fasc” isn’t just among the scariest diagnoses for emergency physicians. the life-and-limb threatening infections “scare the daylights out of everyone,” said mason, co-author of a recent article aimed at closing those gaps in diagnoses and management. for survivors, amputations might be necessary to control the infection. people can lose large amounts of tissue from their chest wall, or neck. recovery can take months.
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the infections are still rare, relative to everything else doctors treat. most will see a handful, if that, in their whole career, mason said, “and yet there’s this huge pressure to make the diagnosis quick.” the infections progress, fast, “like, right in front of you.” most urgently require “wide, serial debridement,” she and her co-authors wrote in the cmaj, meaning cutting away layers of dead skin and tissues, big surgeries people don’t want to get wrong, “because the consequences of getting it wrong are huge. i think that strikes fear in everyone’s hearts.” however, miss it, and the consequences are dire. the death rate is as high as 50 per cent.
the challenge, said critical care physician dr. shannon fernando, is that people often show up in emergency “not super obviously sick, until they’re very late into their course,” which is why cases are so often missed. by the time the necrosis, or dead tissue has spread extensively, vital organs can shut down. “you’re talking higher mortality with every organ that fails,” fernando said.
necrotizing fasciitis results when strep a, normally a relatively harmless bacterium that causes throat infections like strep throat or tonsillitis, enters the skin through a wound, though it can also occur at sites of “non-penetrating trauma,” researchers have reported, like a minor muscle sprain.
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a truck driver in b.c. died in 2018 of sepsis from necrotizing fasciitis that developed on his arms and face, four days after a simple fall from the back of his truck.
the same year, a 57-year-old ontario carpenter’s foot was amputated 10 days after wedging a knee in between pipes while installing a bulkhead.
last year, a nova scotia woman survived a brush with necrotizing fasciitis after the infection spread from a “toonie-sized” patch on the side of one breast to an area as big as “three full hands” of dead tissue across her torso, as global news reported.
former bloc québécois leader lucien bouchard survived a strep infection in 1994 only after surgeons amputated his left leg.
a similar form of the disease, necrotizing pneumonia, killed muppets creator jim henson in 1990.
in december, atlanta rapper og maco died following a reportedly self-inflicted gunshot wound. in march, 2019, og maco revealed on instagram that he had developed necrotizing fasciitis on his face after being ‘improperly treated for a minor rash.’
og maco/instagram
more recently, atlanta rapper og maco, who died in december after suffering a reportedly self-inflicted gunshot wound, developed necrotizing fasciitis on his face in 2019 after being treated for a rash. “i’ve been scared a lot,” he shared on instagram. “i didn’t know if i was going to lose my entire face. i almost did.”
irish actor barry keoghan revealed in a gq cover story last year that he nearly died from necrotizing fasciitis he caught just before shooting commenced for the banshees of inisherin. as gq’s alex pappademas wrote, keoghan now bears a “gnarly scar tissue that winds its way up his arm like a snake tattoo.” in the interview, keoghan recalled saying to doctors, “but i’m not gonna die, right?” and doctors responding, “well, we don’t know.”
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last month, university of nevada reno school of medicine doctors reported the death of a 32-year-old woman who died from a necrotizing wound infection after a caesarean section.
invasive group a streptococcus disease, or igas, has made a resurgence in recent decades, with american cases reaching a 20-year high in 2023. the disease is rising in canada as well: alberta saw a 77 per cent increase in cases from 2022 to 2023, rising year-to-year from 9.8 per 100,000 population to 19 per 100,000. british columbia had the largest number of reports in 2023 compared to previous years, with 600 cases, including 44 cases of flesh-eating disease, and 39 deaths. ontario’s rate in 2023 (12.8 per 100,000 population) was the highest on record since igas became reportable in 1995. cases in ontario doubled from 810 in 2021, to 1,997 in 2023, and the proportion with a fatal outcome is also rising. ontario reported 227 deaths in 2023, up from 102 the previous year, and 46 deaths in 2021.
invasive group a strep don’t always cause necrotizing fasciitis, and necrotizing soft tissue infections can be caused by a mix of other pathogens known as poly-microbial infections. but group a strep is a major cause of the flesh-destroying disease. the bacteria become life-threatening when they invade the blood or spread along the tissues surrounding muscle. and while known risk factors include diabetes or other chronic diseases, a weakened immune system, age 60-plus and injection drug use, about 30 per cent of cases occur in otherwise healthy people.
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symptoms can include a rough looking and exquisitely tender rash, said fernando, a critical care doctor at lakeridge health in oshawa. “but otherwise, they don’t necessarily have classic signs of infection,” like fever, or an elevated white blood cell count. numerous parts of the body can be affected — arms, legs, chest wall, neck.
the “high season” for group a strep, a wholly and exclusively human infection that’s transmitted person-to-person via direct contact with, or inhalation of droplets from a person’s nose or mouth, is winter months and early spring, december through april.
however, the number of serious infections during high season has exceeded what was seen pre-covid, researchers are reporting.
as gq’s alex pappademas wrote, keoghan now bears a “gnarly scar tissue that winds its way up his arm like a snake tattoo.”
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there are two prevailing theories why. one is likely related to covid.
people tend to get fewer strep infections and less strep throat as they get older due to natural immunity built up over the years. many kids, as high as 10 per cent, carry strep around in their throats without causing any kind of disease. school closures and mask mandates during covid meant less exposure to strep. “there’s likely some level of reduced immunity on a population level due to lack of exposure and that would translate into more infections,” said western university biomedical researcher dr. john mccormick, whose lab’s primary focus is on streptococcus.
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the other part of the story is a new strain of strep dubbed m1uk that surfaced in england in 2019 that’s shouldering out older strains. it’s more aggressive and more dangerous, producing nine times more of a particular toxin that can over stimulate the immune system, potentially leading to streptococcus toxic shock syndrome and multi-organ failure.
the hyper-toxic strain has become more prevalent in canada and is causing more cases of invasive group a strep.
chicken pox is also a significant risk factor for developing invasive strep disease, mccormick said. bacteria can enter through lesions on the skin, and kids should be watched for symptoms of invasive group a strep, such as tenderness, swelling or redness of the skin. however, there’s often no identified “portal of entry,” he said. “like, how did it get in? we don’t really know.”
in general, people don’t need to be overly worried, but neither should they be ignoring things that could be strep throat or leading to invasive disease, mccormick said, like a bruise with pain out of proportion to the injury — “it doesn’t look that bad, but it’s extremely painful” — or an infection that’s spreading, or skin colour changes. children with suspected strep throat should be seen by a doctor.
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the gold standard for diagnosing necrotizing fasciitis is surgical evaluation, opening the area and looking for dead tissue. fernando and colleagues have warned that traditional assessment tools like imaging or various blood tests can’t rule out the diagnosis and aren’t particularly good at capturing people with soft tissue infections, but can lead to dangerous delay getting them to the operating room. sometimes “there’s nothing that you see in front of you, but they’re just sick,” dr. saswata deb, an emergency doctor at sunnybrook, said on the cmaj podcast. “we’ve had patients like that where, clinically, there was nothing on a physical exam to say, ‘oh my god, that area looks infected.’”
lots of pain is a big thing, deb said. “it’s a big common sign.” but mason said that “almost nothing should be reassuring, really, once it’s crossed your mind.”
once inside the body from, say a scrape on a knee, the bacteria can enter the bloodstream. blood supply to tissue is “compromised,” causing the tissue to die, and dead tissue acts as further fuel to the fire, mason said, because bacteria thrive in dead tissue.
a colorized scanning electron microscope image of group a streptococcus (pink) during phagocytic interaction with a human neutrophil (green).
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strep can spread with unmatched speed. when mason is cutting out infected and destroyed tissue, she has to get ahead of the damage, trying to draw a “do not pass this point” sign so it can’t spread further. cut out not only the area that’s infected, “but healthy tissue, to act as a barrier.”
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“and we’re pretty bad at the first operation at deciding where the extent of the dissection needs to be,” mason said, because, to the naked eye it can be hard to tell whether the tissue is infected or not, which is why people almost always need to return to the operating room, multiple times, to get control.
mason has removed tissue as small as the size of a person’s handprint, to as large as an entire torso. part of the hesitation, and fear, is how that open wound is eventually going to be closed, or whether it would be too much for people to recover from. “it’s like, ‘how can you possibly survive if i cut your whole flank off,’” mason said on the podcast.
she and her colleagues in burn centres can reconstruct with skin grafts, flaps and other techniques, applying the same principles they use with burn victims. “that care doesn’t have to happen in your hands,” she told listening surgeons, “but i need you to do the debridement first.”
her own hospital has worked to reduce delays that have come out of case reviews. a small incision under local anesthetic can be made in the skin in the emergency room, to feel and look at the tissues more than just skin deep, either to put people’s minds at ease or hurry the patient immediately to the or. dead tissue loses its ‘integrity,” mason explained. it tends to be soft and floppy, like over ripe fruit.
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while necrotizing fasciitis is scary, and doctors do need to worry, people generally “have enough things to worry about and this doesn’t need to be one of them,” mason said.
“but if you are very unwell, you should seek medical attention, especially if you notice a new wound or a new change in your skin that wasn’t there before.”
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