Fatal craniocervical necrotizing fasciitis in an immunocompetent patient: a case report and literature review

Pseudomonas aeruginosa as a culprit of cervical necrotizing fasciitis: A case report

Introduction and importance

Necrotizing fasciitis is usually a polymicrobial infection and odontogenic source is usually the foci for infection in the neck region. Cervical necrotizing fasciitis due to Pseudomonas is a rare and potentially fatal complication in diabetic patients. The study highlights the importance of early intervention to improve the outcome of the patient.

Case presentation

We report a case of a 48-year female who presented with neck pain for 10 days. On further investigations, she had diabetic ketoacidosis, and a culture of the wound showed Pseudomonas. With appropriate antibiotics and surgical intervention, her condition gradually improved.

Clinical discussion

Necrotizing fasciitis in the neck region with Pseudomonas without odontogenic infections is a rare occurrence. Early medical and surgical intervention leads to a better outcome. The location of the infection and its extensions can affect the prognosis.

Conclusion

Physicians should be aware of cervical necrotizing fasciitis as a complication in diabetic ketoacidosis and install early treatment to improve survivability and the outcome.

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The hallmark of necrotizing fasciitis is the extensive necrosis of subcutaneous tissue and underlying fascia.

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Cervical necrotizing fasciitis without contiguous spread is a rare occurrence.

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Early surgical intervention can lead to better outcome of the patient.

Upper Eyelid Necrosis Secondary to Hordeolum: A Case Report

We reported a case of upper eyelid necrosis initially misdiagnosed as a preseptal cellulitis following a hordeolum externum resulting in great damage to the upper eyelid (anterior lamella). The infection was successfully treated with surgical cleansing, drainage, and endovenous antibiotics. Early treatment may avoid severe complications such as eyelid deformity, systemic involvement, and blindness.

Periorbital Necrotizing Fasciitis: Outcomes Using a CT-Guided Surgical Debridement Approach

Purpose

The surgical management of necrotizing fasciitis usually involves early radical/wide and aggressive debridement of involved areas. We describe 5 cases of periorbital necrotizing fasciitis (NF), managed using a computed tomographic (CT)-guided approach to surgical debridement.

Methods

Retrospective case series review.

Results

Five patients (4 female, 1 male; age range 39–81) were treated for periorbital NF. The diagnosis was confirmed in all cases with blood cultures and wound swabs. All patients were managed medically by a surviving sepsis regimen. CT scans confirmed suprafascial infection and excluded orbital cellulitis. Four patients had minimal surgical debridement to the surface muscle. All patients survived. Four out of 5 patients underwent delayed reconstruction.

Conclusions

Periorbital NF behaves differently from NF of other areas. CT-guided surgical debridement of the superficial muscle maximizes preservation of healthy tissue and facilitates reconstruction. Delayed reconstruction allows fibrosis to settle and good cosmetic and functional results are possible. However, NF remains potentially lethal and close observation and a flexible management plan are required.

Necrotizing odontogenic fasciitis of head and neck extending to anterior mediastinum in elderly patients: innovative treatment with a review of the literature

BACKGROUND

Necrotizing fasciitis (NF) of odontogenic origin affecting the head and neck region is a rare but serious clinical condition, which, if diagnosed late, can lead to a fatal outcome. The early diagnosis of necrotizing fasciitis can be difficult. Delay in diagnosis leads to increase in the area of necrosis with a resulting increase in cosmetic deformity and life-threatening complication. In this study, we present two cases of elderly patients with aggressive NF affecting the neck and anterior mediastinum, which were of odontogenic origin.

METHODS

In the two patients selected necrotic skin and soft tissue were removed and wide exposure was achieved with debridement of the neck at the level of the affected layer of superficial cervical fascia. Saline solution was used as irrigation to treat the patients with acute necrotizing fasciitis. Difficulties in managing this condition with NF extent to deep anterior mediastinum is related to clavicle osteotomy or thoracotomy need with high surgical risks. In our technique, by gentle suction in anterior mediastinum, necrotic tissue resection was possible without any osteotomy need.

CONCLUSIONS

Suctioning resection technique associated with hyperbaric, metabolic rebalance, and amino acid support in association with three types antibiotic therapy are fundamental points for correct therapy strategy, leading to full recovery and healing of NF patients even if in very unfavorable conditions. Multidisciplinary approach is paramount for proper treatment of this disease.

Necrotizing fasciitis of the chest wall caused by infected dentigerous cyst: a case report

Necrotizing fasciitis of the chest wall is a fairly uncommon condition. Early diagnosis and treatment is the two main factors responsible for the prognosis. Odontogenic cause of the necrotizing fasciitis of the chest wall is a rare phenomenon. It can be easily missed during the initial examination. Mortality still remains high in necrotizing fasciitis despite the use of modern powerful antibiotics and advances in the care of critically ill patients. The disease manifestation can range from a fulminant presentation to a subtle and insidious development. In this paper we are presenting a case of necrotizing fasciitis of chest wall caused by infected dentigerous cyst.

Management of facial necrotizing fasciitis

Necrotizing fasciitis is a progressive, life-threatening, bacterial infection of the skin, the subcutaneous tissue and the underlying fascia, in most cases caused by ss-hemolytic group A streptococcus. Only early diagnosis and aggressive therapy including broad spectrum antibiotics and surgical intervention can avoid systemic toxicity with a high mortality rate. This uncommon disease generally occurs in the lower extremities and trunk, and only rarely affects the head and neck region. When located in the face necrotizing fasciitis is associated with severe cosmetic and functional restrictions due to the invasive infection and often to the necessary surgical treatment. Generally surgical intervention cannot be performed in the face as aggressively as in the extremities and trunk, since a lot of vital structures are found in a relatively small area. In the following article, we present the successful diagnostic and therapeutic management of an isolated facial necrotizing fasciitis as a consequence of a nasal bone fracture with a minor dermal cut.

Facial necrotizing fasciitis secondary to accidental bite of the upper lip

We describe a case with facial wounds over the left upper lip that became contaminated with saliva. A facial necrotizing fasciitis developed 2 days after injury. This produced a serious and almost fatal infection.

Periorbital necrotising fasciitis: delay in diagnosis results in loss of lower eyelid

Necrotising fasciitis (NF) is an extremely rare skin and soft tissue infection with extensive necrosis of the subcutaneous tissue and underlying fascia, which usually affects the limbs and trunk. It rarely affects the head and neck region because of the excellent blood supply in this region. We report a case of NF initially misdiagnosed as a traumatic pre-septal cellulitis following self-puncture of a hordeolum externum (stye) and its resistance to aggressive antibiotic therapy resulting in the loss of the lower eyelid.

An investigation of the microbial contamination of dental unit air and water lines

AIM

The objective of this study was to measure the microbial contamination released from dental unit air lines (DUAL) and dental unit water lines (DUWL).

MATERIALS AND METHODS

Emissions from DUAL and DUWL from five dental units supplied by a central water source (tap) and a centralised air supply were sampled three times over a five- week period. Air was forced through sterile water and then plated onto selective agar using apparatus designed to spread the sample solution evenly, and then incubated at room temperature for seven days. Colonies were then counted and the concentration of bacteria present was determined and expressed as colony forming units per millilitre (cfu/ml) per minute. The same procedure was used to evaluate five other dental units, which had attached independent water reservoir (bottle) systems (IWR). Only deionised water was added to the bottles and unit waterlines were cleaned weekly with alkaline peroxide based solution. Values were expressed as cfu/ml.

RESULTS

Air and water specimens obtained from dental units supplied with tap water had microbial counts significantly (t-test, p < 0.05) greater than IWR dental units.

CONCLUSIONS

Results indicate that IWR can reduce the numbers of micro-organisms released from DUWL. However, the effectiveness of such systems should be routinely monitored. Emissions from DUAL seems to reflect the levels of microbial contamination present in DUWL.

Paediatric necrotizing fasciitis complicating third molar extraction: report of a case

Necrotizing fasciitis is an uncommon but well-described entity. In the paediatric population compromising risk factors are frequently absent. We describe the successful treatment of a case of cervicofacial necrotizing fasciitis in a healthy 14-year-old male following routine extraction of an uninfected wisdom tooth for orthodontic purposes.

Necrotizing fasciitis of the head and neck: a report of two patients and review

BACKGROUND

Necrotizing fasciitis is a disfiguring condition that can be fatal. The head and neck region is rarely affected. However, when involved, the functional and cosmetic sequelae can be considerable.

MATERIALS AND METHODS

We present two case histories, discuss salient diagnostic points, treatment, and review published data on this topic.

RESULTS

With a timely diagnosis we were able to diagnose and appropriately treat these patients.

CONCLUSIONS

Necrotizing fasciitis is a disfiguring condition that can be fatal if not diagnosed in a timely fashion. Diagnosis and treatment require a high index of suspicion, immediate operative intervention, broad-spectrum antibiotics, and appropriate supportive care.

Craniocervical necrotizing fasciitis in Ile-Ife, Nigeria

Sixteen cases of necrotizing fasciitis were seen at the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria from 1990 to 2000. Primary craniocervical involvement was recorded in seven patients (five men and two women). The clinical records of five patients were sufficiently detailed to allow us to report their age, aetiology, predisposing illness, clinical features, complications, management regimen and outcome. The patients were aged 30-75 years and in four of them odontogenic infections were the cause of the condition. Hypertension, diabetes mellitus and obesity were the underlying systemic diseases in three cases and the body/angle region of the mandible was the predominant site of the infection on the face. All five cases had involvement of the neck. Mediastinal extension was recorded in three cases. Two patients had complications: one had septicaemia and renal failure and the other developed bone necrosis. Pre-existing ill health, old age, late surgical intervention, and mediastinal and thoracic extension of infection were responsible for the only death. Treatment involved frequent and multiple surgical debridement, aggressive antimicrobial treatment and control of systemic disease. Early recognition, prompt surgical intervention, and aggressive antimicrobial treatment are essential to minimize morbidity and mortality. Rapid progression of infection, financial constraints, delayed referrals from rural clinics and distance to the tertiary hospital caused problems.

Craniocervical necrotizing fasciitis: an 11-year experience

OBJECTIVE

We review our experience and present our approach to treating craniocervical necrotizing fasciitis (CCNF).

STUDY DESIGN

All cases of CCNF treated at Wayne State University/Detroit Receiving Hospital from January 1989 to April 2000 were reviewed. Patients were analyzed for source and extent of infection, microbiology, co-morbidities, antimicrobial therapy, hospital days, surgical interventions, complications, and outcomes.

RESULTS

A review of 250 charts identified 10 cases that met the study criteria. Five cases (50%) had spread of infection into the thorax, with only 1 (10%) fatality. An average of 24 hospital days (7 to 45), 14 ICU days (6 to 21), and 3 surgical procedures (1 to 6) per patient was required.

CONCLUSION

Aggressive wound care, broad-spectrum antibiotics, and multiple surgical interventions resulted in a 90% (9/10) overall survival and 80% (4/5) survival for those with thoracic extension.

SIGNIFICANCE

This is the largest single institution report of CCNF with thoracic extension identified to date.

Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases

PURPOSE

Although most cases of cervical necrotizing fasciitis (CNF) are odontogenic in origin, reports of this disease in the dental literature are sparse. The purpose of this study was to review the cases treated on our service, and to analyze the features of this disease and the responses to management, to supplement the understanding of this relatively rare and life-threatening disease.

PATIENTS AND METHODS

All cases of infection admitted to the OMS service in a period of 10.5 years were studied retrospectively. The diagnosis of CNF was established by the findings on surgical exploration and histologic examination. The patients' age, sex, medical status, causes of the infection, bacteriology, computed tomography scan findings, surgical interventions, complications, survival, and other clinical parameters were reviewed.

RESULTS

A total of 422 cases of infection were admitted, and 11 cases of cervical necrotizing fasciitis were found. The incidence of CNF was 2.6% among the infections hospitalized on the OMS service. There were 7 male and 4 female patients. Eight patients were older than 60 years of age. Seven patients had immunocompromising conditions, including diabetes mellitus in 4, concurrent administration of steroid in 2, uremia in 1, and a thymus carcinoma in 1. All patients showed parapharyngeal space involvement; four also showed retropharyngeal space involvement. Gas was found in the computed tomography scan in 6 patients, extending to cranial base in 3 of them. Anaerobes were isolated in 73% of the infections, whereas Streptococcus species were uniformly present. All patients received 1 or more debridements. Major complications occurred in 4 patients, including mediastinitis in 4, septic shock in 2, lung empyema in 1, pleural effusion in 2, and pericardial effusion in 1. All major complications developed in the immunocompromised patients, leading to 2 deaths.

CONCLUSION

The mortality rate in this study was 18%. Early surgical debridement, intensive medical care, and a multidisciplinary approach are advocated in the management of CNF.

Interleukin-1 receptor signaling rather than that of tumor necrosis factor is critical in protecting the host from the severe consequences of a polymicrobe anaerobic infection

Infection of the dental pulp leads to an osteolytic lesion that results from a polymicrobial infection consisting largely of pathogenic anaerobes. Infection causes significant morbidity and mortality mediated by bacterial factors and in some cases by the up-regulation of inflammatory cytokines. The inflammatory cytokines interleukin-1 (IL-1) and tumor necrosis factor (TNF), in particular, play a complex and central role in the responses to microbial pathogens. However, relatively little is known about the significance of these cytokines in protecting the host from focal polymicrobial anaerobic infections. To establish the relative importance of IL-1 and TNF in mediating the response to a mixed anaerobic infection, we inoculated the dental pulp of mice with six anaerobic pathogens containing functional deletions of receptors to IL-1 (IL-1R1(-/-)), TNF (TNFRp55(-/-)-p75(-/-)), or both (TNFRp55(-/-)-IL-1RI(-/-)). The results indicate that IL-1 receptor signaling and TNF receptor signaling both play similarly important roles in protecting the host from local tissue damage. However, IL-1 receptor signaling is considerably more important than TNF receptor signaling in preventing the spread of infection into surrounding fascial planes, since IL-1R1(-/-) but not TNFRp55(-/-)-p75(-/-) mice exhibited significantly higher morbidity and mortality. Moreover, all of the fatal infections occurred in male mice, suggesting the importance of gender differences in limiting the impact of these infections.

Necrotizing fasciitis after peritonsillar abscess in an immunocompetent patient

Cervical necrotizing fasciitis (CNF) is a rapidly progressive, severe bacterial infection of the fascial planes of the head and neck. Group A beta haemolytic Streptococcus spp. (GABHS), Staphylococcus spp., or obligatory anaerobic bacteria are the most common causative pathogens. The disease usually results from a dental source or facial trauma. Extensive fascial necrosis and severe systemic toxicity are common manifestations of CNF. Review of the literature reveals only seven such cases, with four successful outcomes. The authors present the case of a 50-year-old immunocompetent female with CNF arising from a peritonsillar abscess. Intravenous immunoglobulins in conjunction with surgery and antibiotics were used successfully. The authors also suggest the importance of the early diagnosis, aggressive surgical debridement, broad-spectrum antibiotics, and possible usefulness of the intravenous immunoglobulins in the treatment of CNF, especially when the disease is associated with toxic shock syndrome.

Cervical necrotizing fasciitis

Cervical necrotizing fasciitis (CNF) is an aggressive infection of the head and neck with high complication and mortality rates. Sixty-eight cases of CNF have been reported in the English-language literature. We present a series of 8 patients with CNF, including 5 men and 3 women ranging in age from 25 to 92 years. To the best of our knowledge, this is one of the largest case series reported. Six of the 8 patients had a predisposing odontogenic focus of infection. Four patients had mediastinal involvement. Two patients, both with significant comorbidity at the time of presentation, died of CNF.