Surgical implications of pseudomonas aeruginosa necrotizing fasciitis in a child with acute lymphoblastic leukemia

Monomicrobial Necrotizing Fasciitis and Sepsis Caused by Pseudomonas aeruginosa and Pseudomonas fluorescens: A Series of Ten Cases

Monomicrobial necrotizing fasciitis caused by Pseudomonas species is a rare infection. The purpose of this study was to elucidate the specific characteristics and clinical outcomes of necrotizing fasciitis caused by Pseudomonas aeruginosa and Pseudomonas fluorescens. Ten patients with monomicrobial necrotizing fasciitis caused by Pseudomonas species were retrospectively reviewed over an 8-year period. Differences in mortality, patient characteristics, clinical presentations, laboratory data, and clinical outcomes were compared between the death and the survival groups. Two patients died with the mortality rate of 20%. Pseudomonas aeruginosa accounted for 9 patients and Pseudomonas fluorescens for one patient. The most common comorbidity is type 2 diabetes mellitus in 5 patients. We found the death patients had lower albumin level and higher counts of band forms of leukocytes than those of the survival patients. Monomicrobial necrotizing fasciitis caused by Pseudomonas species needs emergent surgical intervention and aggressive intensive care due to high mortality rate. We reported the first case of monomicrobial necrotizing fasciitis with Pseudomonas fluorescens. Severe hypoalbuminemia and increased counts of banded leukocytes in initial laboratory presentations can be considered as poor prognostic factors.

Reconstruction of the Scrotum With Bilateral Gracilis Muscle Rotational Flaps in a Patient With Acute Myeloid Leukemia Complicated by Fournier’s Gangrene

We describe the case of a 43-year-old male diagnosed with acute myeloid leukemia complicated by Fournier’s gangrene. Multiple debridements led to the complete effacement of the scrotum, with 360 degrees of exposed testes and a narrow base of suspension. It was decided to reconstruct the scrotum using bilateral gracilis muscle rotational flaps, followed by split-thickness skin grafting from the thigh. The gracilis muscle as a donor flap allowed for the protection and support of the testes and suspensory tissue while achieving an aesthetically pleasing result that resembled the normal scrotum. We hope providers will consider this reconstructive method in future patients who present with similar extensive effacement of the scrotal tissue.

Fournier's Gangrene in Patients with Oncohematological Diseases: A Systematic Review of Published Cases

Patients suffering from hematological malignancies are at increased risk of Fournier's gangrene (FG) due to immunosuppression caused by the disease itself or by disease-related treatments. A systematic review of PubMed, ISI Web of Knowledge, and Scopus databases was performed in June 2021. We included full papers that met the following criteria: original research, human studies, and describing clinical presentation, treatment, and outcomes of FG in patients with oncohematological diseases. We identified 35 papers published from 1983 to 2021 involving 44 patients (34 males, 8 females) aged between 4 days and 83 years. The most common malignant hematological disorders were acute myeloid leukemia (n = 21) and acute lymphocytic leukemia (n = 9). In 10 patients FG represented the first presentation of hematological malignancy. Scrotum (n= 27) and perineum (n = 11) were the sites most commonly involved. Pseudomonas aeruginosa (n = 21) and Escherichia coli (n = 6) were the most commonly isolated microorganisms. Surgery was performed in 39 patients. Vacuum-assisted closure and hyperbaric oxygen therapy were adopted in 4 and in 3 patients, respectively. Recovery was achieved in 30 patients. FG-related mortality was observed in 11 patients. FG should be carefully considered in patients with oncohematological diseases.

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

Successful Use of Negative-pressure Wound Therapy and Dermal Substitute in the Treatment of Gluteal Ecthyma Gangrenosum in a 2-year-old Girl

Ecthyma Gangrenosum is a manifestation of Pseudomonas Aeruginosa infection, usually occurring in immunocompromised patients, which can be associated with Pseudomonas Aeruginosa bacteremia with potentially lethal outcome. The clinical appearance is of an inflammatory cutaneous lesion with a central necrotic spot; the lesion then rapidly progresses to a gangrenous ulcer with a gray-black eschar extending in the deep soft tissues. Treatment of Ecthyma Gangrenosum includes both aggressive systemic antibiotic therapy and surgical procedures. A 2-year-old girl affected by B-cell precursor acute lymphoblastic leukemia was admitted to our hospital for suspected sepsis; the diagnosis was later confirmed by blood cultures positive for Pseudomonas Aeruginosa. In the days following the diagnosis, the patient developed a necrotic lesion of the right gluteal area consistent with Ecthyma Gangrenosum. Aggressive surgical debridement was then performed, followed by negative-pressure wound therapy and reconstruction with dermal substitute and autologous skin graft, which were successful. Ecthyma Gangrenosum is a potentially lethal condition affecting especially immunocompromised patients; aggressive medical treatment with combination antibiotic therapy is warranted and multiple surgical procedures, including extensive surgical debridement and diverting colostomy, are needed. Various reconstructive techniques have been reported in the literature, although no gold-standard can be established to date. Since Ecthyma Gangrenosum lesions are characterized by the presence of both high inflammatory activity due Pseudomonas infection and extensive tissue loss, the association of negative-pressure therapy and dermal substitutes implant seem to have a rationale in the surgical treatment of Ecthyma Gangrenosum and should therefore be considered.

Excessive pediatric fasciitis necrotisans due to Pseudomonas aeruginosa infection successfully treated with negative pressure wound therapy

The case of a 10-year old female child is described with a history of myeloproliferative disorder having skin, bone and visceral involvement. Bone marrow biopsy revealed histiocytosis X. During chemotherapy necrotizing fasciitis of the lower abdominal wall was diagnosed. Multiple microbiological cultures taken from the wound base revealed Pseudomonas aeruginosa infection. Surgical necrectomy and application of negative pressure wound therapy (NPWT) was started together with intensive care treatment for sepsis. As both wound and general condition of the patient improved, autologous split thickness skin grafting was carried out in two sitting under continuing NPWT application. The applied skin grafts showed excellent take, the perilesional subcutaneous recesses resolved and complete healing was achieved after 28 days of NPWT treatment. Proper dermatological diagnosis and immediate escharectomy complemented with application of NPWT can be life-saving in the treatment of necrotizing fasciitis.

Necrotising fasciitis caused by P aeruginosa in a male patient with chronic lymphocytic leukaemia

A 53-year-old man with chronic lymphocytic leukaemia and multiple comorbidities presented with a 2-day history of increasing pain and swelling in his left leg following a minor trauma, associated with signs of systemic sepsis and worsening multiorgan failure. The clinical picture was consistent with necrotising fasciitis and he was taken to the theatre for an above-knee amputation. Blood and tissue cultures grew Pseudomonas aeruginosa only, which is very rare as a monomicrobial infection, with relatively few cases being reported in the literature. The combination of aggressive timely surgical intervention, broad-spectrum antibiotics and treatment on the intensive care unit yielded a successful outcome from this acute episode.

Necrotizing fasciitis caused by Serratia marcescens after venous access port implantation in a child with acute lymphoblastic leukemia

Necrotizing fasciitis is a potentially life-threatening infection of deep skin layers and subcutaneous tissues that can easily spread across the fascia plate and is usually the result of a combined infection with anaerobic and aerobic microorganisms. The patient typically complains of excruciating pain, which is not necessarily in accordance with clinical signs. Early recognition of the condition is very important, and aggressive treatment with a combination of antibiotics and surgical procedure is crucial. We present a case of a 15-year-old girl with acute lymphoblastic leukemia who developed necrotizing fasciitis after venous access port implantation during induction chemotherapy.

Negative pressure treatment for necrotizing fasciitis after chemotherapy

We describe 2 cases of children with malignant disease who developed severe mucositis with perineal necrotizing fasciitis during severe neutropenia after chemotherapy. Treatment with topical negative pressure therapy with silver foam dressing, together with large spectrum antibiotics, resolved the problem with complete closure of the wound after 30 and 36 days of treatment, respectively.

Necrotizing fasciitis caused by Pseudomonas aeruginosa

An 85-year-old man patient was admitted to the hospital complaining of fever and bilateral leg pain with swelling and erythema. A laboratory investigation revealed leukocytopenia, thus suggesting sepsis. Gram negative rods were detected in the specimen from the affected skin and empiric antibacterial therapy was initiated. The following day, his symptoms worsened and Pseudomonas aeruginosa was isolated from the blood culture and the skin specimen. Magnetic resonance imaging (MRI) did not show the typical characteristics of necrotizing fasciitis. In spite of intensive medical treatment, the patient's condition became critical, and on day 10 after admission, he died of multiple organ failure. An autopsy revealed necrotizing fasciitis due to P. aeruginosa. This is a rare case and its clinical presentation was atypical. The clinical diagnosis of this infection may be difficult, and therefore such cases warrant the careful attention of physicians.

Necrotizing fasciitis in neonates

Necrotizing fasciitis (NF) is a potentially life-threatening infection of soft tissues. It is characterized by rapid spread of inflammation and infection with widespread necrosis of fascia, subcutaneous tissues, and overlying skin. NF is usually reported in adults with preexisting medical conditions or compromised immune system. It is rare in neonates, and the reported mortality is close to 50% in this population. Less than 70 cases of neonatal NF are reported in literature, most in otherwise healthy neonates and usually attributed to omphalitis, mastitis, or postoperative wound infections. We report our experience of nine neonates who developed NF spontaneously (primary NF) and look at the etiology, clinical presentation, microbiology, management, and outcome.