Necrotising soft tissue infection following mastectomy

Necrotizing Fasciitis of the Breast Requiring a Life-Saving Mastectomy: A Case Report and Literature Review

Necrotizing soft tissue infection of the breast is an extremely rare event in routine surgical practice. It is the most aggressive form of soft tissue infection and a real surgical emergency. It is associated with a high risk of mortality if not diagnosed promptly. A Literature search has revealed only a few such cases. The exact etiology is variable and very often multifactorial. Early recognition and prompt surgical treatment along with broad-spectrum antibiotic therapy are of paramount importance to prevent mortality. In this report, we present the first case of necrotizing fasciitis of the breast following an insect bite in the literature, in a 57-year-old diabetic patient with a delayed presentation that required a life-saving mastectomy.

Management of Primary Necrotizing Fasciitis of the Breast: A Systematic Review

Purpose

Necrotizing fasciitis (NF) is a life-threatening infection that involves spreading necrosis of the subcutaneous tissue and fascia that affects the extremities, abdominal wall, and perineum. Primary infection of the breast is a rare occurrence. Shah et al described the first case of primary breast NF and recommended radical "pseudotumor" excision and delayed skin closure months after resolution. Numerous other cases reported were successfully managed with different strategies. We aimed to summarize management options for primary breast NF through a systematic review of the literature.

Methods

A systematic review of English literature was performed using PubMed. A total of 58 abstracts were reviewed. Data were abstracted from 25 cases that met inclusion criteria.

Results

A total of 25 cases of primary NF of the breast without an inciting event were found within the literature. Common initial operations included total mastectomy (36.0%), excisional debridement (32.0%), and partial mastectomy (12.0%). A total or radical mastectomy was completed for definitive source control in 13 (52.0%) cases. A total of 18 cases underwent reconstruction. Split-thickness skin grafts (44.4%) and delayed primary closures (33.3%) were the most common methods of reconstruction.

Conclusion

Majority of cases with primary breast NF are managed with a total mastectomy to gain source control. Reconstruction using split-thickness skin grafts was most common. Other options included delayed primary closure, full thickness skin grafts, local tissue rearrangement, and pedicle flap reconstruction. Reconstruction should be patient dependent, but the whole arsenal of the reconstructive ladder may be used.

Necrotizing Fasciitis of the Breast: A Review of the Literature

Background: Necrotizing fasciitis (NF) is a rare, rapidly progressing, and potentially fatal tissue infection involving subcutaneous tissue, superficial fascia, and the overlying skin. Breast NF is often misdiagnosed because of the thick breast tissue between the skin and deep fascia. Only early diagnosis followed by prompt antibiotic treatment and surgical therapy can prevent disastrous consequences. There are many case reports on breast NF, but a systematic review is lacking. Methods: Using PubMed and Scopus we performed a systematic review of the literature covering a period of 20 years. We reviewed articles with predisposing comorbidities (risk factors), triggering factors, laboratory examinations, culture of organisms, antibiotic treatment, surgical interventions, the presence of septic shock, and final outcome. We also performed statistical tests of all these factors in relation to death. Results: Forty cases identified from 38 articles were included in our literature review. Twenty-one cases (52.5%) were primary, whereas 15 cases (37.5%) occurred after surgery. In 15 cases (37.5%), the single organism responsible for NF was Streptococcus pyogenes, whereas mixed organisms were found in 17 cases (42.5%). Surgical debridement was performed in 39 (97.5%) cases. Septic shock was found in all five (12.5%) deceased cases and was associated with patient's mortality (p < 0.001). Conclusions: Breast NF is a rare, severe, and easily misdiagnosed complication. Breast NF could differ from that in other body regions in etiology pattern and clinical manifestations. Confirmed diagnosis of breast NF is based on the combination of clinical, cultural, laboratory, and imaging findings. Urgent subsequent treatments, including surgical debridement, antibiotic therapy, and reconstructive surgery, are critical for better prognosis and survival of patients.

Necrotizing fasciitis of the breast managed by partial mastectomy and local tissue rearrangement

Necrotizing fasciitis (NF) of the breast is a rare occurrence that is routinely misdiagnosed as an abscess or cellulitis, resulting in treatment delays. A total mastectomy is required when delays occur. We present a 53-year-old female with breast NF managed with a partial mastectomy and local tissue rearrangement.

A case report of primary necrotising fasciitis of the breast: A rare but deadly entity requiring rapid surgical management

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Primary necrotising fasciitis of the breast is an extremely rare entity.

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We present the youngest patient described in the literature.

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Prompt resuscitation and surgical intervention are critical to successful management.

Introduction

Necrotising fasciitis of the breast is a rare entity with very few cases reported in the literature. It is rapidly progressive and can lead to sepsis and multi-organ failure without prompt medical and surgical management.

Presentation of case

We describe a case of a non-diabetic 23-year-old female with primary necrotising fasciitis of the right breast. She presented in septic shock with gross breast discolouration and nipple discharge. Immediate resuscitation followed by muscle-sparing mastectomy within 3 h of her presentation was performed. She was managed postoperatively in intensive care. Complications included myocardial infarction and anuria requiring continuous renal replacement therapy. She eventually recovered with close to normal cardiac function and was discharged home after skin grafting of her mastectomy wound.

Conclusion

This is the youngest patient with primary necrotising fasciitis of the breast described in the literature. Prompt resuscitation and an aggressive surgical approach are critical to the successful management of this life threatening pathology.

Management of Necrotizing Fasciitis and Its Surgical Aspects

Necrotizing fasciitis (NF) is a severe and rapidly progressive infectious disease that attacks superficial an as well as deep fascia, subcutaneous fat tissue, and muscle. Although the incidence is of relatively low frequency, the median mortality is high. NF is a great burden to patients and hospitals. The most common cause of NF is trauma injuries, followed by other conditions with comorbidity. A classification for NF was presented concerning microbial cause, depth of infection, and anatomy. But the value of classification is not convincing. Early diagnosis of NF is essential and still to be realized by far. Information from clinic or laboratory might contribute to the purpose. Surgery is used in exploration debridement and tissue reconstruction as the main method with NF. Negative pressure wound therapy has proved to be useful in improving wound bed preparation and healing.

Primary necrotising fasciitis of the breast: case report and brief review of literature

Necrotizing fasciitis is a rapidly spreading progressive infection of the fascia with necrosis of the subcutaneous tissues. Primary necrotising fasciitis of the breast is extremely rare and hence we report the case of a 55-year-old woman presenting to our hospital with primary necrotising fasciitis of the breast in a state of systemic septic shock. She was admitted in surgical intensive care unit and treated with resuscitation, intravenous antibiotics and aggressive debridement. We discuss the details of the case, our treatment approach, the outcome and also briefly review the literature.

Breast necrotising fasciitis managed by partial mastectomy

We present the case of a 75-year-old woman who presented with extensive breast cellulitis, which was thought to be secondary to a deep breast abscess. On admission the patient underwent debridement of the breast and broad-spectrum intravenous antibiotics were administered. However, during hospitalisation she developed sepsis, acute renal failure and required further debridements for the rapidly spreading necrotising fasciitis. Subsequently, a partial mastectomy was performed and the patient made an overall good postoperative recovery.