Streptococcal necrotizing fasciitis with toxic shock syndrome following cervical adenitis

Cervical Necrotizing Fasciitis and Shock in the Post-Operative Pediatric Patient

Cervical necrotizing fasciitis (CNF) is a rare infection that can quickly lead to devastating patient outcomes. Considering the vital importance of surrounding neck structures, rapid control of the infection is essential. Infection is most frequently polymicrobial and occurs in the adult patient in the context of certain medical comorbidities. Complications are typically limited to tissue destruction in the form of necrosis. There are no current reports describing CNF complicated by acute shock in the post-operative pediatric patient. Here, we present a pediatric case of CNF complicated by acute shock following Sistrunk procedure for removal of a supposed thyroglossal duct cyst. This case illustrates a potential post-operative complication that can be seen within the pediatric patient. Although most reported examples of CNF are polymicrobial and result from odontogenic infection, providers should be aware of other potential sources of disease. It is important for the pediatric surgeon to rapidly identify CNF and consequent shock, as prompt medical and surgical interventions are critical to offering the best chance of patient survival.

A case report of necrotizing soft tissue infection of the chest wall: Effective management with serial debridement

Introduction

Necrotizing soft tissue infection (NSTI) of the chest wall is a rare, rapidly spreading, highly lethal surgical disease. Radical debridement interferes with the important anatomical function of the chest wall. We report a case of chest wall NSTI that was successfully managed with early diagnosis and serial debridement.

Presentation of case

A 43-year-old, previously healthy woman presented with severe malaise and worsening right axillary pain. She was severely lethargic and had a painful, large, pale lesion with surrounding erythema of the right chest and trunk. Computed tomography revealed NSTI, with diffuse soft tissue inflammation extending from the axilla to the lower abdomen. There was no obvious entry portal. Prompt surgical drainage was established. Group A streptococcus infection was diagnosed. During her 3-month postoperative course, she underwent four more surgeries, including two debridements. This treatment proved successful and avoided the need for complicated muscle flap reconstruction. She was discharged on postoperative day 109.

Discussion

Group A streptococcus can cause NSTI even in immunocompetent patients without an entry portal. Radical debridement is recommended for infection control. Preserving anatomical chest wall function, however, is also important. Serial debridement with close follow-up solved the problem in this patient.

Conclusions

Serial debridement with close follow-up enabled to avoid large tissue deficits and complicated reconstruction in the case of NSTI of the chest wall.

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Necrotizing soft tissue infection of the chest wall is rare and lethal.

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Radical debridement could interfere with the anatomical function of the chest wall.

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Adequate drainage with minimum skin incision avoids large tissue defects.

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Serial debridement with close follow-up enabled to avoid complicated reconstruction

Treatment of Diabetic Foot Ulcers With Necrotizing Fasciitis in the Lower Leg Using the STAGE Principles: A Report of 9 Cases With a Literature Review

Diabetic foot ulcers (DFUs) combined with necrotizing fasciitis (NF) has rapid onset, involves a wide range of lesions, is difficult to treat, and has a high mortality rate. It has become a clinically critical disease. DFU patients are at high risk for NF. The STAGE principles guide surgical intervention in the treatment of DFU wounds and emphasizes that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." This work reports the application of the STAGE principles for the treatment of 9 cases of DFUs combined with NF in the lower leg (Wagner grade 3-5). The mean ankle-brachial index was 0.55 (0-0.91, standard deviation [SD] = 0.33), the mean years of smoking were 19.56 years (0-50, SD = 17.83), and the mean cigarette consumption was 9.11 cigarettes/day (0-20, SD = 7.77). The mean duration of ulcers was 45.56 days (3-103, SD = 35.44). Among the 9 patients, only patient no. 9 died, and the mean follow-up time for the other 8 patients was 12 months (3-36, SD = 13.42). In short, the STAGE principles are also applicable to the treatment of DFUs combined with NF in the lower leg.

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.

Epidemiologic analysis of dental cellulitis in Kinshasa city (the Democratic Republic of the Congo)

Introduction: The study aimed to determine the prevalence, describe the sociodemographic profile of individuals with dental cellulitis, and identify its associated factors in a population of Kinshasa. Materials and methods: This was a cross-sectional analytical study conducted in October 2017 in five hospital departments in Kinshasa. The sample population consisted of patients with dental cellulitis. Sociodemographic data and factors associated with dental cellulitis were evaluated. Results: Dental cellulitis was found in 12.5% of the subjects, with a slight female predominance (58.2%). A significant difference between patients with cellulitis and those without cellulitis was observed for the following variables: education level, unemployment, and low socioeconomic status (p < 0.05). Dental carious lesions (93.7%) were the most common causative factor, and self-medication (100%) and poor oral hygiene (83.5%) were risk or contributing factors. Univariate analysis showed that for people of ages 16–59 and ≥60 years, education level, unemployment, sugar consumption, and low socioeconomic status were significantly associated with dental cellulitis. A multivariate logistic regression analysis showed that people of ages ≥60 years [odds ratio (OR) 3.12, 95% confidence interval (CI) 1.169–4.14, p = 0.014], non-university status (OR 2.79, 95% CI 1.68–4.64, p < 0.001), unemployment (OR 2.27, 95% CI 1.73–4.20, p = 0.005), sugar consumption (OR 3.17, 95% CI 1.71–4.94, p = 0.036), and low socioeconomic status (OR 2.60, 95% CI 1.85–3.01, p = 0.014) were independently associated with dental cellulitis in the study population. Conclusion: Dental cellulitis is a public health problem in the city of Kinshasa, the Democratic Republic of Congo.

Senile Lemierre syndrome complicated with descending necrotizing mediastinitis: A case report

RATIONALE

Senile patients with LS complicated with DNM are rarely seen in clinical practice, and extensive cervical incision and drainage plus administration of effective antibiotics are the basis for treatment. Currently, the treatment controversy mainly has focused on whether mediastinal incision and drainage is necessary for patients with type I DNM, and whether anticoagulation therapy is required for jugular venous emboli and distant metastatic emboli induced by LS.

PATIENT CONCERNS

A female, 76 years old, developed pain of tonsil on right side 5 days ago, and felt that the pain aggravated complicated with dysphagia and swelling pain of neck on both sides since then.

DIAGNOSES

She was diagnosed with LS complicated with type I DNM.

INTERVENTIONS

Tazobactam and Piperacillin 4.5 q8h and Ornidazole 100 ml q6h ivgtt were administered empirically,and secondary extensive cervical incision and drainage was performed under general anesthesia, after which low molecular weight heparin 4250 U q12h SC was administered. G test was performed 3 days later, which showed (1,3)-β-D-glucan >1000 pg/ml. Bridging anticoagulation therapy, low molecular weight heparin 4250 U q12h SC, and Warfarin 2.5 mg qd po were given one week later. Low molecular weight heparin SC was discontinued and only Warfarin po was administered after treatment of bridging therapy for 3 days.

OUTCOMES

CT of head and neck was reexamined on post-admission d24 and revealed that neck infection was improved on both sides, jugular vein distension on right side was restored to normal, abscess and pneumatosis of superior mediastinum were improved, distension of pulmonary artery on both sides was normalized, WBC was 9.94×109/L, neutrophil count was 4.43×109/L, CRP level was 9.8mg/L, D-D level was 0.81mg/L, PCT level was 0.800ng/mL and G test suggested (1,3)-β-D-glucan pf 27.1 pg/mL.

LESSONS

Concomitant use of anticoagulants on the basis of repeated cervical incision and drainage + administration of effective antibiotics can obtain excellent therapeutic efficacy in the treatment of patient with LS complicated with type I DNM.

Does diclofenac increase the risk of cervical necrotizing fasciitis in a rat model?

Non-steroidal anti-inflammatory drugs (NSAIDs) are known for aggravating in vitro infections and were reported in many cases of cervical necrotizing fasciitis (CNF). We developed a rat model of CNF, mimicking as closely as possible the human-CNF, to study the effect of a NSAIDs, diclofenac, as a promoting factor. Twenty rats were injected bilaterally in the neck with peptostreptococcus and with a fresh saliva specimen for another 20 rats. Half of each group was given an intramuscular injection of 4 mg/kg diclofenac at the time of inoculation and 24 h later, and the other half saline injections; rats were killed at day 7 and clinical, bacterial and histological studies were performed to assess the infectious process and the incidence of CNF. No statistically significant difference was found between groups treated with diclofenac vs. the saline injection groups. However a significant correlation was noted between clinical observation, bacterial density and histological signs of inflammation. CNF has a high mortality rate and the use of NSAIDs in conditions potentially leading to CNF is very common. However, our rat model does not support the hypothesis of a promoting role of diclofenac which was occasionally suggested in the medical literature. This study suggests that diclofenac does not seem to increase the risk of occurrence of CNF. Nonetheless, NSAIDs can mask inflammatory signs of an already spreading CNF.

Cervical necrotizing fasciitis with mediastinitis: a rare occurrence in the pediatric age

Necrotizing fasciitis (NF) is a life-threatening, progressive, bacterial soft tissue infection characterized by necrosis of skin, subcutaneous tissues, fasciae, and muscles. It usually occurs in adults and is most often localized to the abdominal wall, the extremities, the perineum, the pelvis, and the thoracic region. Localization to the head and neck area is rarely encountered, especially in pediatric patients. Early diagnosis and prompt, aggressive surgical treatment associated with intravenous, broad-spectrum antibiotic therapy are mandatory to successfully control the disease. To date, only anecdotal cases of cervical NF in the pediatric age have been described. We report a case of cervical NF with mediastinitis in a 13-year-old girl who underwent successful immediate surgery and prolonged intravenous antibiotic therapy. A literature review is also presented with particular emphasis on etiology, clinical and radiological presentation, diagnosis, and treatment of this rare disorder.

Cervical complications following routine tonsillectomy and adenoidectomy

PURPOSE OF REVIEW

Fortunately, patients undergoing adenotonsillectomies have far more complaints than complications. Sore throats, dysphagia, and neck pain are frequent and expected symptoms after surgery. Differentiating these symptoms from early signs of severe cervical complications can be difficult. Such complications are rare but include atlanto-axial subluxation (Grisel's syndrome), cervical necrotizing fasciitis, cervical emphysema and cervical oseteomyelitis. Due to the frequency with which adenotonsillectomies are performed, most otolaryngologists will encounter these events during their career. This article is thereby intended to elucidate the early warnings, appropriate diagnostic workup, and therapeutic modalities for cervical complications following adenotonsillectomies.

RECENT FINDINGS

Early recognition and intervention can prevent devastating morbidity and mortality described with cervical complications. Computed tomography scanning remains the gold standard for diagnosing cervical complications after adenotonsillectomy. Although a range of severity exists in cervical complications, most cases can be managed conservatively with broad spectrum antibiotics, observation, bedrest and immobilization in cases of Grisel's syndrome. Cervical necrotizing fasciitis requires a high index of suspicion and urgent management to avoid fatal consequences.

SUMMARY

This is a review of the most frequently encountered, although rare, cervical complications following adenotonsillectomies. It gives the reader an insight into the efficient diagnosis and management of these complications.