Periorbital necrotizing fasciitis due to Klebsiella pneumoniae in an immunocompetent patient.

A 52-year-old female presented with complaints of bilateral painful lid swelling since 2 days. On examination, there was bilateral lid edema with periocular skin necrosis and eschar formation [Fig. 1a]. The necrotic skin had a wooden consistency (like a thick tree bark) and was insensitive to tactile and painful stimuli. A clinical diagnosis of periorbital necrotizing fasciitis (PNF) was made and immediate surgical debridement was performed. During surgery, debridement was done till plane of vital tissue (identified as petechial hemorrhages and till nociceptive stimuli elicited a positive response) was reached [Fig. 1b]. Evaluation of the debrided tissue and the purulent discharge showed the presence of Gram-negative bacilli, and parenteral amikacin was administered. Subsequently, microbial cultures grew Kleibsella pnuemoniae sensitive to amikacin. Complete blood counts were normal and serology was negative for HIV. Daily wound care with slough removal from wound base, excision of new necrotic skin at the margins, and wound dressing with gauze soaked in povidone iodine and amikacin was done. Parenteral amikacin was continued for two weeks till no pus could be exuded from the ulcer margin following tactile pressure, and till the ulcer base stopped sloughing. Subsequently, healthy granulation tissue was observed at 1 month [Fig. 1c], and spontaneous scar formation with resolution of the cutaneous defect by 2 months aided by conservative local therapy [Fig. 1d].

Figure 1

(a) Periorbital necrotizing fasciitis at presentation (b) Immediate post debridement with vital tissue in the wound bed (c) Healthy pink granulation tissue can be seen at the bed of the healing ulcer (d) Complete resolution of skin defect and scar formation

PNF usually occurs after trauma (75% have a positive history), especially in immunocompromised patients. It carries a high risk of mortality.[12] Streptococcus is the most common single organism responsible, followed by Pseudomonas. To our knowledge, this is the first report of PNF due to Kleibsella pnuemoniae. PNF has few peculiar features and different behavior from necrotizing fasciitis elsewhere in the body. The blood rich orbicularis acts as a barrier to the spread of infection to the orbit. Since the dermis is attached to the nasojugal fold medially and malar fold laterally there is some resistance to the spread of infection to the cervicofacial region. However, if these barriers are breached, the infection spreads rapidly to the thoracic skin leading to further complications such as septicemia, toxic shock, and multiorgan failure. Tissue healing in PNF is accompanied by cicatrisation which may lead to ectropion and exposure keratopathy, and require lid surgeries for rehabilitation.[2]

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