Fungal Periorbital Necrotizing Fasciitis in an Immunocompetent Adult

A case of necrotizing fasciitis of the orbit secondary to Aspergillus fumigatus and mixed flora

A 79-year-old female presented to the emergency department for sudden-onset ocular pain, edema, and erythema around her left eye. She also had a left-sided migraine and frontal fullness for 2 weeks. She had attentive care for the diagnosis of orbital cellulitis and prompt recognition of necrotizing fasciitis. Wound cultures were positive for over 5 strains of bacteria in addition to Aspergillus. In a combined effort by our institution's Ophthalmology and Otolaryngology departments, the patient was successfully treated with debridement, porcine bladder matrix, antibiotics, and antifungals. The authors describe the first reported case of eyelid and periorbital necrotizing fasciitis, caused by mixed flora and Aspergillus fumigatus, that showed promising wound healing with the outlined treatment paradigm.

Candida albicans necrotizing fasciitis following elective surgery

Necrotizing fasciitis is a potentially fatal soft tissue infection that requires prompt clinical suspicion, pharmacological and surgical interventions. Bacterial pathogens, such as beta-hemolytic streptococcus and Staphylococcus aureus, are the main etiology of necrotizing fasciitis, however, rare cases caused by fungal pathogens, such as Candida albicans, have been reported following trauma. Here, we present the first case of C. albicans necrotizing fasciitis following an elective surgical procedure in an immunocompetent adult.

Periorbital Necrotizing Fasciitis Secondary to Candida parapsilosis and Streptococcus pyogenes

Necrotizing fasciitis is most often caused by either polymicrobial bacterial infections or by Gram-positive organisms, such as Streptococcus or Staphylococcus; however, rare cases of fungal necrotizing fasciitis have been reported. Candida parapsilosis is an emerging fungal pathogen. This fungus grows in either a yeast or pseudohyphal form. C. parapsilosis has been reported to cause keratitis, intraocular infection, and seeding of frontalis slings. C. parapsilosis is a commensal of human skin and can be acquired by nosocomial spread. Necrotizing fasciitis due to Candida has rarely been reported, but to date C. parapsilosis has not been identified as the causative organism in necrotizing fasciitis. This is the first documented case of human periocular soft tissue infection by C. parapsilosis, and also the first report providing evidence of mycotic infection in a necrotizing fasciitis concurrently infected by Streptococcus pyogenes.

Fungal Infections Increase the Mortality Rate Three-Fold in Necrotizing Soft-Tissue Infections

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) result in significant morbidity and mortality rates, with as many as 76% of patients dying during their index admission. Published data suggest NSTIs rarely involve fungal infections in immunocompetent patients. However, because of the recent recognition of fungal infections in our population, we hypothesized that such infections frequently complicate NSTIs and are associated with higher morbidity and mortality rates.

METHODS

A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with NSTIs. Microbiologic data, demographics, and clinical outcomes were abstracted. Risk factors and outcomes associated with NSTI with positive intra-operative fungal cultures were determined. Frequencies were compared by χ² and continuous variables by the Student t-test using SPSS. Because the study included only archived data, no patient permission was needed.

RESULTS

A total of 230 patients were found to have NSTIs; 197 had intra-operative cultures, and 21 (10.7%) of these were positive for fungi. Fungal infection was more common in women, patients with higher body mass index (BMI), and patients who had had prior abdominal procedures. There were no significant differences in demographics, co-morbidities, or site of infection. The majority of patients (85.7%) had mixed bacterial and fungal infections; in the remaining patients, fungi were the only species isolated. Most fungal cultures were collected within 48 h of hospital admission, suggesting that the infections were not hospital acquired. Patients with positive fungal cultures required two more surgical interventions and had a three-fold greater mortality rate than patients without fungal infections.

CONCLUSIONS

This is the largest series to date describing the impact of fungal infection in NSTIs. Our data demonstrate a three-fold increase in the mortality rate and the need for two additional operations. Consideration should be given to starting patients on empiric anti-fungal therapy in certain circumstances.

Periorbital necrotizing fasciitis -- a review

Necrotizing fasciitis (NF) is a severe infection characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin. Periorbital NF is uncommon because of the excellent blood supply to that area; nevertheless, it can sometimes result in death. The aim of this study is to present a systematic review and analyse the factors associated with death. We carried out a systematic literature review of all cases of periorbital NF published in the English language over the past 20 years and present the predisposing conditions, triggering factors, organisms causing NF, presence or absence of toxic shock and the prognosis. The significance of various risk factors leading to death was analysed. We traced a total of 94 patients with periorbital NF from 61 reports. There were no triggering incidents in 25 cases (26.6%). In 48 cases (51.1%), the organism responsible for NF was Group A beta haemolytic Streptococcus. Toxic shock occurred in 29 (30.9%) cases, and loss of vision in 13 (13.8%). Surgical debridement was carried out in 80 (85.1%) cases. There were eight cases (8.5%) of death. This seems to be less than previously reported figures. Toxic shock syndrome (p < 0.001), type 1 infections (p = 0.018), facial involvement (p = 0.032) and blindness because of periorbital NF (p = 0.035) were significantly associated with mortality. Mortality caused by NF arising from the periorbital area seems to be on the decline. However, it is important to recognize it early and institute treatment to avoid toxic shock that leads to death. Type 1 infections, although rare in periorbital area, are not associated with immunocompromised status and nevertheless carry a significant risk of mortality. Major morbidity is loss of vision followed by soft-tissue defects affecting function and cosmesis.

Reverse masquerade syndrome: fungal adnexal infection mimicking carcinoma in a HIV-positive patient

A known HIV-positive male patient presented with a rapidly progressive ulcerative lesion involving the conjunctiva, lids, and anterior orbit along with a decrease in vision in the right eye. He was on anti retro-viral and anti-tubercular therapy. In view of the clinical features, our provisional clinical diagnosis was a malignant lesion of the eyelid with orbital involvement, possibly squamous cell carcinoma. However, incisional biopsy revealed absence of malignant cells. On Gomori Methenamine Silver staining, plenty of fungal filaments were seen, which was confirmed by culture as Candida albicans. Hence, it turned out to be a case of fungal adnexal infection mimicking carcinoma in a HIV-positive patient. The patient responded well to systemic anti-fungals.