Necrotizing fasciitis and gangrene associated with topical herbs in an infant

A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018

BACKGROUND

Necrotising fasciitis is a rapidly progressing soft-tissue infection with a low incidence that carries a relevant risk of morbidity and mortality. Although necrotising fasciitis is often fatal in adults, its case fatality rate seems to be lower in children. A highly variable clinical presentation makes the diagnosis challenging, which often results in misdiagnosis and time-delay to therapy.

METHODS

We conducted a protocol-based systematic review to identify specific features of necrotising fasciitis in children aged one month to 17 years. We searched 'PubMed', 'Web of Science' and 'SCOPUS' for relevant literature. Primary outcomes were incidence and case fatality rates in population-based studies, and skin symptoms on presentation. We also assessed signs of systemic illness, causative organisms, predisposing factors, and reconstructive procedures as secondary outcomes.

RESULTS

We included five studies reporting incidence and case fatality rates, two case-control studies, and 298 cases from 195 reports. Incidence rates varied between 0.022 and 0.843 per 100,000 children per year with a case-fatality rate ranging from 0% to 14.3%. The most frequent skin symptoms were erythema (58.7%; 175/298) and swelling (48%; 143/298), whereas all other symptoms occurred in less than 50% of cases. The majority of cases had fever (76.7%; 188/245), but other signs of systemic illness were present in less than half of the cohort. Group-A streptococci accounted for 44.8% (132/298) followed by Gram-negative rods in 29.8% (88/295), while polymicrobial infections occurred in 17.3% (51/295). Extremities were affected in 45.6% (136/298), of which 73.5% (100/136) occurred in the lower extremities. Skin grafts were necessary in 51.6% (84/162) of the pooled cases, while flaps were seldom used (10.5%; 17/162). The vast majority of included reports originate from developed countries.

CONCLUSIONS

Clinical suspicion remains the key to diagnose necrotising fasciitis. A combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotising fasciitis. Incidence and case-fatality rates in children are much smaller than in adults, although there seems to be a relevant risk of morbidity indicated by the high percentage of skin grafts. Systematic multi-institutional research efforts are necessary to improve early diagnosis on necrotising fasciits.

Case series of necrotizing fasciitis presenting to the Department of Emergency Medicine, Singapore General Hospital, from 2006 to 2012

Introduction:

We aim to review the clinical course of patients with necrotizing fasciitis (NF) presenting to the emergency department, hence determining the need for close monitoring for deterioration, and the need for urgent and rapid surgical intervention.

Methods:

A retrospective review of electronic medical records of patients with the main diagnosis of NF presenting to the Department of Emergency Medicine, Singapore General Hospital, from 2006 to 2012 was performed. Data was collected in standardized forms and used for analysis. Patients’ demographics, LRINEC scores, time to disposition, and clinical course and outcome were reviewed.

Results:

A total of 27 cases with the main diagnosis of NF were reviewed. The median age was 56 years (range 20–79). Twenty-four (88.9%) cases had significant underlying comorbidities. Only 18 (66.7%) cases had a LRINEC score of six or more, mandating careful evaluation for NF. Seven (25.9%) cases were managed in the resuscitation room, with median time taken from registration to resuscitation room being 14 min (range 0–231). Four (14.8%) cases were sent to the operation theater from the emergency department with a median time 321.5 min (range 286–436). Case fatality rate in this series was 14.8%.

Conclusions:

NF can result in gross morbidity and mortality if not treated in the early stages. The emergency physician needs to have a high index of suspicion to recognize the disease early and initiate prompt resuscitative efforts in septic patients, including urgent referral for surgical debridement.

A systematic review of the reporting of adverse events associated with medical herb use among children

PURPOSE

Information about the safety of herbal medicine often comes from case reports published in the medical literature, thus necessitating good quality reporting of these adverse events. The purpose of this study was to perform a systematic review of the comprehensiveness of reporting of published case reports of adverse events associated with herb use in the pediatric population.

METHODS

Electronic literature search included 7 databases and a manual search of retrieved articles from inception through 2010. We included published case reports and case series that reported an adverse event associated with exposure to an herbal product by children under the age of 18 years old. We used descriptive statistics. Based on the International Society of Epidemiology's "Guidelines for Submitting Adverse Events Reports for Publication," we developed and assigned a guideline adherence score (0-17) to each case report.

RESULTS

Ninety-six unique journal papers were identified and represented 128 cases. Of the 128 cases, 37% occurred in children under 2 years old, 38% between the ages of 2 and 8 years old, and 23% between the ages of 9 and 18 years old. Twenty-nine percent of cases were the result of an intentional ingestion while 36% were from an unintentional ingestion. Fifty-two percent of cases documented the Latin binomial of the herb ingredients; 41% documented plant part. Thirty-two percent of the cases reported laboratory testing of the herb, 20% documented the manufacturer of the product, and 22% percent included an assessment of the potential concomitant therapies that could have been influential in the adverse events. Mean guideline adherence score was 12.5 (range 6-17).

CONCLUSIONS

There is considerable need for improvement in reporting adverse events in children following herb use. Without better quality reporting, adverse event reports cannot be interpreted reliably and do not contribute in a meaningful way to guiding recommendations for medicinal herb use.

Integrative medicine in allergy and immunology

Integrative medicine is a relatively new discipline which attempts to combine allopathic medicine with alternative or complementary medicine, to reap the benefits of both forms of medicine in optimizing the care of patients. Integrative medicine concentrates on treating the patient as a whole, both in body and mind. While the scientific method and "evidence-based" clinical research drives the management and treatment of diseases in conventional Western medicine, alternative or complementary medicine is based on unproven yet potentially beneficial techniques that have been developed throughout history, dating back to the ancient cultures in the Middle East, Africa, and China. In spite of the lack of evidence of most alternative medicine techniques, these methodologies have been practiced for centuries with great acceptance in many countries. It is in the Western world, where "modern" medicine is dictated by the scientific method, that the most controversy in the use of these alternative modes of therapy exists. Since the science behind alternative medicine is incomplete or non-existent, it is difficult for those trained in Western medicine to accept or adopt this approach. But perhaps it is the failure of Western medicine to adequately guarantee our well being and good health that have led to the ongoing debate between the medical profession and the general public as to the benefits of these alternative treatments. In one sense, integrative medicine may be a futile attempt to coin a new term in the hope of legitimizing alternative medicine. On the other hand, there is a wealth of historical experience in the use of the techniques. Studies to evaluate the scientific basis behind ancient medical techniques are ongoing, and it is to be expected that the results will neither be uniformly positive nor negative. Of particular interest is the effect of traditional medicine, herbal formulations, and manipulative techniques on the immune system, and its application in the treatment of autoimmune and allergic diseases. Studies are being designed or conducted to investigate immune effects of herbal formulations or their components. Herbal plants or medicines may lead to skewing of the Th1/Th2 balance in either direction, thus may offer potential application in the treatment of allergic or autoimmune diseases.

Cupping Therapy May be Harmful for Eczema: A PubMed Search

Eczema is a common childhood atopic condition and treatment is with emollients, topical corticosteroids, and avoidance of possible triggers. S. aureus colonization is a common complication. As there is no immediate cure, many parents seek alternative therapies that claim unproven therapeutic efficacy. We report a girl with long history of treatment noncompliance. After practicing a long period of dietary avoidance and supplementation, the grandparents took her to an alternative medicine practitioner. Following cupping therapy and acupuncture, the child developed blistering and oozing over her back the next day, which rapidly evolved to two large irregular-edge deep ulcers. She was treated with intravenous antibiotics and received multidisciplinary supportive intervention. Using search words of  “cupping,” “eczema,” and “atopic dermatitis,” only two reports were found on PubMed. Therapeutic efficacy was claimed but not scientifically documented in these reports. Childhood eczema is an eminently treatable atopic disease. Extreme alternative therapy seems not to be efficacious and may even be associated with serious undesirable sequelae. Physicians should be aware of various alternative treatment modalities and be prepared to offer evidence-based advice to the patients with eczema and their families.

Paradoxical use of oral and topical steroids in steroid-phobic patients resorting to traditional Chinese medicines

BACKGROUND

Childhood-onset eczema is a common condition associated with pruritus, sleep disturbance and disrupted quality of life. The mainstay of treatment is usage of emollients and topical corticosteroid (CS). Nevertheless, many steroid-phobic parents are very skeptical about western medicine that may contain CS. Furthermore, complementary and alternative medicine (CAM) is popular among Chinese patients in Asia and many citizens idolize CAM and believe that traditional Chinese medicine and herbs are without any side effects. Pressed by public's quest for efficacious and safe treatment, and lucrative profits, CAM practitioners may take the risks of prescribing steroids and "western medicine" in the name of traditional Chinese herbal medicine.

METHODS

We report a series of illustrative cases of uninformed systemic and topical corticosteroid usage for eczema by steroid-phobic parents to alert the public of this risk. The drugs were detected by high-performance liquid chromatography with diode-array detection, liquid chromatography-tandem mass spectrometry, gas chromatography mass spectrometry, or liquid chromatography ion trap time-of-flight mass spectrometry.

RESULTS

Five cases of uninformed corticosteroid usage for moderate-to-severe eczema by steroid-phobic parents were reported.

CONCLUSIONS

The physician caring for children with skin disease should also be aware that even steroid-phobic parents might indeed be using potent CS without awareness. The patient usually suffers chronic relapsing eczema of moderate-to-severe degree. The steroid-phobic parent is usually non-compliant in following advice on usage of emollient, topical CS, and avoidance of triggers in accordance with western doctors. The CAM practitioner, when confronted by an anxious steroidophobic parent who demands efficacious topical and/or systemic treatment, may knowingly or unknowingly be forced into prescribing potent albeit illegal products containing corticosteroids in the name of traditional Chinese herbal medicine.

Necrotising fasciitis caused by adulterated traditional Asian medicine: a case report

Necrotising fasciitis can be life threatening, requiring prompt diagnosis and surgical debridement. We report a case of necrotising fasciitis caused by an adulterate traditional Asian medication--Jamu Pegal Linu, containing toxic levels of phenylbutazone and dipyrone. The patient presented with severe neutropenia and sepsis. An urgent extensive debridement was carried out (within 6 hours of presentation). Repeated debridements were performed on days 2 and 5, augmented with antibiotics and granulocyte colony-stimulating factor.