Unusual associations of necrotizing fascitis: a case series report from a tertiary care hospital.

Necrotizing fasciitis is a rapidly progressive, potentially fatal infection of the superficial fascia and subcutaneous tissue. It is rare in children. We report three such cases in which differentiating from common soft tissue infection was challenging. High index of suspicion is important as management initiated at an early stage is rewarding.

Introduction

Necrotizing fasciitis (NF) is a rare, rapidly progressive, and potentially fatal infection of the superficial fascia and subcutaneous tissue.[1] NF is rare in children.[2] It has been reported in 0.03% of the hospitalization causes and in 0.08 per 100,000 children per year.[3] Differentiating NF from common soft tissue infections such as cellulitis and impetigo are both challenging and critically important. Prompt diagnosis is imperative because NF typically spread rapidly and can result in multiorgan failure.[4]

We report the cases of three children with NF whom we came across in our hospital, NRS Medical College and Hospital, Kolkata.

Case Reports

Case 1

A two-year-old boy was admitted with history of a small abscess on right thigh and high fever five days back. The right thigh became swollen, indurated with bluish black discoloration two days prior to admission [Figure 1]. There was history of measles two months back. As soon as the child was admitted, blood culture was sent and I.V. antibiotic started. Gradually the area became necrotic with crust formation. The child developed a similar indurated and erythematous lesion on right side of chest which subsequently became necrotic [Figure 2]. Blood culture revealed Citrobacter, and culture from the necrotic area showed growth of Staphylococcus aureus.

Figure 1

Necrotizing fasciitis of right thigh in case 1

Figure 2

Necrotizing fasciitis of right side of chest in case 1

Surgical debridement of the wound, intravenous antibiotic according to the sensitivity pattern, and regular dressing resulted in slow healing of the wound leaving a deep scar.

Case 2

An eight-year-old girl had cellulitis of left hand following a trivial injury by the spike of a cycle. Similar lesion developed on the left leg. The cellulitis on hand subsided on treatment but the left thigh became swollen, indurated, and edematous. There was reddish discoloration and deep necrosis [Figure 3]. Blood culture was negative, but culture from the wound revealed Pseudomonas aeruginosa and S. aureus. The child was treated with intravenous antibiotics and supportive measures followed by debridement.

Figure 3

Showing necrotizing fasciitis on left thigh of case 2. Removal of the crust shows fascial tissue and brown grayish secretion

Case 3

An 11-year-old girl presented with a history of cellulitis on posterolateral aspect of right thigh following thorn prick associated with high-grade fever 10 days prior to hospital admission. Pus was drained surgically from the lesion. Local examination revealed a 10 × 9 cm necrotic area, discharging fluid and ulcer with slough on its floor [Figure 4]. The culture of pus showed growth of Escherichia coli, and the blood culture was sterile. The child was provided intensive treatment with early debridement, intravenous antibiotics followed by skin grafting on a healthy granulation tissue bed two weeks later. Follow-up showed secondary healing.

Figure 4

Showing necrotizing fasciitis on posterolateral aspect of right thigh of case 3 which revealed a 10 × 9 cm necrotic area, discharging fluid and ulcer with slough on its floor

Discussion

NF is characterized by involvement of soft tissue of deep dermis, adipose tissue, and subcutaneous fascia. Hallmark of the disease is extensive areas of both necrosis and cellulitis. Predisposing factors vary with age.[5] Some cases in children are associated with immunosuppressive diseases such as acute lymphoblastic leukemia and malnutrition. Initiating factors reported in the literature include minor injuries, surgical and traumatic wounds, contusion, and varicella infection. In a number of cases, initiating factors cannot be identified. In newborns, omphalitis, circumcision, and placement of electrodes for monitoring vital signs have been reported as initiating factors.[6] Group A β-hemolytic Streptococci has been the most frequently incriminated agent.[7] Many other bacteria and fungi may be involved. Pseudomonas has been implicated as an important causal agent in patients with neutropenia.[8] In the first case who was immunosuppressed due to measles, growth of Citrobacter was observed in blood culture which is not reported yet in association with NF, and coagulase-positive Staphylococcus was recovered from the necrotic area.[9] In the second case, there was mixed infection with Pseudomonas and S. aureus. Citrobacter and other coliform organisms as well as opportunistic pathogens are responsible for a wide range of infection, especially when skin and mucosa may be breached by disease or trauma as noted in our third case. Immunosuppressive states also increase the risk of infection. Clinical manifestations in NF start around a week after the initiating event, followed 24 to 48 hours later by erythema or purple discoloration. After 48 to 72 hours, the skin turns smooth, bright, and the serous or hemorrhagic blisters develop. Without treatment, necrosis develops and by the fifth or sixth day, the lesion turns black with necrotic crusts [Figure 2]. Removal of the crust shows fascial tissue and brown grayish secretion [Figure 3]. Sometimes the presence of gas (produced by aerobic and anaerobic bacteria) is recognized by tissue crepitation.[10] Necrosis of the superficial fascia is always more extensive than skin necrosis. The diagnosis is confirmed during surgical debridement by the presence of liquid necrosis of the superficial fascia.[11]

Once the vital signs and hydro-electrolyte balance are stable, extensive surgical debridement of necrotic tissue must be performed under broad spectrum antibiotic cover. Once culture findings and bacterial sensitivity are obtained, antibiotics should be administered accordingly. Antibiotics alone, because of their inability to reach the poorly vascularized and necrotic fascia, have little effect if surgery is not performed. The benefit of hyperbaric oxygen in NF remains controversial. Other poorly tested therapies include high doses of intravenous globulin, granulocyte transfusion, granulocyte colony—stimulating factor (in granulocytopenic patient), and bovine thymic extract.[8]