Skip to main content
SpringerLink
Log in

Distinguishing necrotizing from non-necrotizing fasciitis: a new predictive scoring integrating MRI in the LRINEC score

  • Musculoskeletal
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

To develop and validate a scoring system integrating MRI and laboratory findings to differentiate necrotizing fasciitis (NF) from non-necrotizing fasciitis (non-NF).

Methods

This retrospective study included 144 subjects who underwent surgery in one of three tertiary referral centers for NF or cellulitis with non-NF. The development cohort consisted of 96 subjects (NF = 47; non-NF = 49) from one center, and the validation cohort consisted of 48 subjects (NF = 23; cellulitis with non-NF = 25) from two different centers. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system and five MRI findings (thickening of the intermuscular deep fascia ≥ 3 mm, extensive involvement of the deep fascia, multi-compartmental involvement in one extremity, presence of gas, and contrast-enhancement pattern) were included in univariate and multivariate logistic regression analysis to identify independent predictors of NF. An additive scoring system was developed using the coefficients of the final regression model. Model performance was assessed for discrimination and calibration. The scoring system was externally validated.

Result

The final scoring system consisted of three variables: thickening of the deep fascia ≥ 3 mm, multi-compartmental involvement, and LRINEC score. The new predictive model showed improved performance (area under the receiver operating characteristic curve [AUC], 0.862; positive and negative predictive values, 82% and 79%, respectively), compared with the LRINEC score alone (0.814, 77% and 67%, respectively). The model also showed good discrimination with the external validation dataset (AUC, 0.933).

Conclusions

Differentiation of NF from severe cellulitis with non-NF can be achieved with the new predictive scoring system.

Key Points

• The new predictive scoring system integrating two MRI findings with the LRINEC score can help in the differentiation of necrotizing fasciitis from severe cellulitis with non-necrotizing fasciitis.

• Thickening of the deep fascia ≥ 3 mm and multi-compartmental involvement were the most important MRI findings for the differentiation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Abbreviations

AUC:

Area under the receiver operating characteristic curve

CRP:

C-reactive protein

LRINEC:

Laboratory Risk Indicator for Necrotizing Fasciitis

MRI:

Magnetic resonance imaging

NF:

Necrotizing fasciitis

NPV:

Negative predictive value

PPV:

Positive predictive value

ROC:

Receiver operating characteristic

WBC:

White cell count

References

  1. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO (2003) Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 85-A(8):1454–1460

    Article  Google Scholar 

  2. Sarani B, Strong M, Pascual J, Schwab CW (2009) Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg 208(2):279–288

    Article  PubMed  Google Scholar 

  3. Wong CH, Khin LW, Heng KS, Tan KC, Low CO (2004) The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 32(7):1535–1541

    Article  PubMed  Google Scholar 

  4. Holland MJ (2009) Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score to patients in a tropical tertiary referral centre. Anaesth Intensive Care 37(4):588–592

    Article  CAS  PubMed  Google Scholar 

  5. Sirikurnpiboon S, Sawangsangwattana T (2017) Early diagnosis of necrotizing fasciitis using Laboratory Risk Indicator of Necrotizing Fasciitis (LRINEC) score. J Med Assoc Thail 100(Suppl 1):S192–S199

    Google Scholar 

  6. Bechar J, Sepehripour S, Hardwicke J, Filobbos G (2017) Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature. Ann R Coll Surg Engl 99:341–346

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Swain RA, Hatcher JC, Azadian BS, Soni N, De Souza B (2013) A five-year review of necrotising fasciitis in a tertiary referral unit. Ann R Coll Surg Engl 95(1):57–60

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Wilson MP, Schneir AB (2013) A case of necrotizing fasciitis with a LRINEC score of zero: clinical suspicion should trump scoring systems. J Emerg Med 44(5):928–931

    Article  PubMed  Google Scholar 

  9. Syed A, Alvin T, Fazrina A, Abdul R (2017) Determining if positive predictive value using Laboratory Risk Indicator for Necrotising Fasciitis is applicable in Malaysian patients with necrotising fasciitis. Malays Orthop J 11(2):36–39

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Al-Hindawi A, McGhee J, Lockey J, Vizcaychipi M (2017) Validation of the laboratory risk indicator for necrotising fasciitis scoring system (LRINEC) in a Northern European population. J Plast Reconstr Aesthet Surg 70(1):141–143

    Article  PubMed  Google Scholar 

  11. Fernando SM, Tran A, Cheng W et al (2018) Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis. Ann Surg. https://doi.org/10.1097/SLA.0000000000002774

  12. Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC (2013) Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Joint Bone Spine 80(2):146–154

    Article  PubMed  Google Scholar 

  13. Kim KT, Kim YJ, Won Lee J et al (2011) Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging? Radiology 259(3):816–824

    Article  PubMed  Google Scholar 

  14. Brothers TE, Tagge DU, Stutley JE, Conway WF, Del Schutte H Jr, Byrne TK (1998) Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity. J Am Coll Surg 187(4):416–421

    Article  CAS  PubMed  Google Scholar 

  15. Fugitt JB, Puckett ML, Quigley MM, Kerr SM (2004) Necrotizing fasciitis. Radiographics 24(5):1472–1476

    Article  PubMed  Google Scholar 

  16. Rahmouni A, Chosidow O, Mathieu D et al (1994) MR imaging in acute infectious cellulitis. Radiology 192(2):493–496

    Article  CAS  PubMed  Google Scholar 

  17. Schmid MR, Kossmann T, Duewell S (1998) Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol 170(3):615–620

    Article  CAS  PubMed  Google Scholar 

  18. Ali SZ, Srinivasan S, Peh WC (2014) MRI in necrotizing fasciitis of the extremities. Br J Radiol 87(1033):20130560

    Article  CAS  PubMed  Google Scholar 

  19. Sullivan LM, Massaro JM, D'Agostino RB Sr (2004) Presentation of multivariate data for clinical use: the Framingham Study risk score functions. Stat Med 23(10):1631–1660

    Article  PubMed  Google Scholar 

  20. Egan JP (1975) Signal detection theory and ROC analysis. Academic Press, New York

    Google Scholar 

  21. Lemeshow S, Hosmer DW Jr (1982) A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 115(1):92–106

    Article  CAS  PubMed  Google Scholar 

  22. DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44(3):837–845

    Article  CAS  PubMed  Google Scholar 

  23. Cohen J (1968) Weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit. Psychol Bull 70(4):213–220

    Article  CAS  PubMed  Google Scholar 

  24. Neeki MM, Dong F, Au C et al (2017) Evaluating the laboratory risk indicator to differentiate cellulitis from necrotizing fasciitis in the emergency department. West J Emerg Med 18(4):684–689

    Article  PubMed  PubMed Central  Google Scholar 

  25. Loh NN, Ch'en IY, Cheung LP, Li KC (1997) Deep fascial hyperintensity in soft-tissue abnormalities as revealed by T2-weighted MR imaging. AJR Am J Roentgenol 168(5):1301–1304

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Jung Bok Lee, Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, for his advice on statistical analysis.

Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea

    Min A Yoon, Hye Won Chung, Yujin Yeo, Choong Guen Chee, Min Hee Lee, Sang Hoon Lee & Myung Jin Shin

  2. Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea

    Hye Jin Yoo

  3. Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumidong, Bundang-Gu, Seongnam City, Gyeonggi-do, 13620, South Korea

    Yusuhn Kang

Authors
  1. Min A Yoon
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hye Won Chung
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yujin Yeo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hye Jin Yoo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yusuhn Kang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Choong Guen Chee
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Min Hee Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sang Hoon Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Myung Jin Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hye Won Chung.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Hye Won Chung.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Jung Bok Lee, from Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• retrospective

• diagnostic or prognostic study

• multicenter study

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yoon, M.A., Chung, H.W., Yeo, Y. et al. Distinguishing necrotizing from non-necrotizing fasciitis: a new predictive scoring integrating MRI in the LRINEC score. Eur Radiol 29, 3414–3423 (2019). https://doi.org/10.1007/s00330-019-06103-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-019-06103-0

Keywords

Search

Navigation