Necrotizing Fasciitis of the Chest Wall: Report of Pediatric Cases

Case report of open appendectomy in treating acute perforated appendicitis with necrotizing fasciitis of the abdominal wall: A rare complication of a common disease

Acute appendicitis can be associated with uncommon complications such as necrotizing fasciitis. We present a case of a 37-year-old woman referred to our hospital with a 1-week history of significant weakness, anorexia, and mild abdominal pain. According to laboratory and radiographic data, the patient was diagnosed with perforated appendicitis and gangrene.

E. coli Monomicrobial Necrotizing Fasciitis in an Iron-Overloaded Adolescent

Escherichia coli is an extremely unusual cause of monomicrobial necrotizing fasciitis of the extremities in children. We report a transfusion-dependent adolescent boy with iron-overload secondary to congenital dyserythropoietic anemia who developed severe E. coli monomicrobial necrotizing fasciitis of the leg following a minor trauma. Combined surgical, antimicrobial and supportive care resulted in a good outcome.

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.

Necrotic Lesions Following Elective Urological Surgery in an Infant

Case Report  An 11-month-old female infant presented on the first postoperative (PO) day following an elective pyeloplasty, a dark bluish erythema of her lumbotomy wound, plus a satellite lesion of the same characteristics. Fever and sepsis developed, and despite broad spectrum antibiotics (meropenem and vancomycin) were started, a diagnosis of necrotizing soft-tissue infection (NSTI or necrotizing fasciitis) was established. Surgical debridement of both lesions was performed on day 3 PO, and a surgical contamination (ring retractor blade) was suspected, due to the particular geography of the lesion. Urine and blood cultures yielded no bacteria, but tissue culture grew Pseudomonas aeruginosa . At PO 6th day, lesions still appeared exudative and poorly perfused, so vacuum-assisted therapy (VAT) treatment was started. Exudate control, perfusion, and granulation improved in consecutive days, which permitted direct closure (no graft needed) at PO day 12.

Discussion   P. aeruginosa can be a fatal cause of type I NSTI. It has been reported rarely in adult series, with a prevalence of 4%, but it can be a major pathogen in pediatric NSTI. Added to an early recognition, aggressive surgery and debridement are required, in combination with antibiotic therapy, to limit the spread of the infection. In our case, despite surgical debridement being performed on day 3 PO, both wounds maintained scarce perfusion, and debris and exudate were poorly controlled with usual silver foams and daily nursery cures. VAT pediatric device was then added, which rapidly improved surgical bed, enhancing tissue perfusion and granulation in the following days.

Pediatric Necrotizing Fasciitis: Restitutio Ad Integrum after Early Diagnosis and Aggressive Surgical Treatment

Necrotizing fasciitis (NF) is a severe, life-threatening infectious condition. Diagnosis is difficult due to unspecific symptoms yet crucial for favorable outcomes. We report a case of a 1 year old, previously healthy boy, where early suspicion of NF led to prompt aggressive therapy and consecutive restitutio ad integrum.