Necrotizing fasciitis associated with systemic lupus erythematosus in a child.

Sir,

We read with interest the response to our article “Necrotizing fasciitis associated with systemic lupus erythematosus in a child”.[1] The author has commented on two issues. About the first comment regarding consideration of concomitant diagnosis of cutaneous mucoromycosis (CM), we agree that CM should be considered in the differential diagnosis of necrotic wounds not responding to conventional therapy. Diagnosis of CM, when suspected, is based on histopathological identification of zygomycetes with the finding of wide branching aseptate hyphae.[2] Fungal culture may not yield positive results in many cases, and may be of only academic interest in view of the rapid course of the disease. In our case tissue biopsy for histopathological examination did not show any fungal elements, which excluded the diagnosis of necrotizing fasciitis caused by fungi. We thus considered the infection to be of polybacterial origin, a common finding in this condition, and managed appropriately. Prognosis of necrotizing fasciitis depends on timely diagnosis and management. Diagnostic delay in necrotizing fasciitis has a high mortality rate ranging from 15% to 73%.[3] A rapid clinical deterioration is frequently seen in NF. In our patient, mortality may be attributed to delayed diagnosis and treatment, due to late presentation to a tertiary care center, along with underlying systemic lupus erythematosus-induced immunosuppression.

In their second comment, the authors have elucidated the different associations of systemic lupus erythematosus with necrotizing fasciitis. In our case, the child presented with necrotizing fasciitis, but was incidentally diagnosed to have occult systemic lupus erythematosus.

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