Necrotizing fasciitis

Necrotising fasciitis: experience with 32 children

BACKGROUND

Necrotising fasciitis (NF) in children is rare, rapidly progressive and potentially fatal. A satisfactory outcome depends on early diagnosis and aggressive surgical debridement, along with appropriate antibiotic therapy.

AIM

The aim was to describe the various presentations of NF and evaluate outcome of treatment.

PATIENTS AND METHODS

This was a 4-year prospective, descriptive study of all consecutive cases of NF aged 15 years and under treated at Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria from January 2001 to December 2004.

RESULTS

Thirty-two children were treated during the study period. The male:female ratio was 1.7:1. Ages ranged from 6 days to 12 years (mean 2 yrs). The commonest predisposing factors were malnutrition (40.6%), boils (37.5%) and intravenous canulation (9.4%). Duration of symptoms ranged from 3 to 19 days (mean 6.4) and the total body surface areas involved ranged from 2% to 16% (mean 5.9%). Half of the patients presented with involvement of the trunk, followed by head/neck (28.1%), upper limbs (21.9%), lower limbs (6.3%) and perineum (6.3%). Most patients had polymicrobial infection, but the organism most commonly isolated was Staphylococcus aureus (71.9%). All patients were resuscitated and had surgical wound debridement, antibiotics and wound care. Final wound resurfacing was by secondary intention (46.9%), direct suturing (6.3%), split thickness skin grafting (21.9%) and local flap reconstruction (12.5%). Septicaemia was the commonest complication (71.9%). The mortality rate was 9.4%. Duration of hospital stay ranged from 14 to 96 days (mean 27.6). Follow-up ranged from 3 weeks to 6 months (mean 52.4 days).

CONCLUSION

NF in children is not uncommon in Nigeria. It is associated with significant morbidity, but mortality can be reduced remarkably by early diagnosis and aggressive treatment.

Surgical aspects of bacterial infection in African children

Infections and their complications requiring surgical intervention are a frequent presentation in African children. Surgical site infection (SSI) is common with rates over 20%, even after clean procedures. The high rates of SSI are due in part to lack of infection control and surveillance policies in most hospitals in Africa. SSI is attended by complications, long hospital stay, and some mortality, but the economic consequences are unestimated. Typhoid fever and typhoid intestinal perforation are major problems with perforation rates of approximately 10%, which is higher in older children. The ideal surgical treatment is arguable, but simple closure and segmental resection are the present effective surgical options. Because of delayed presentation, complications after surgical treatment are high with a mortality approaching 41% in some parts of Africa. Nutrition for these patients remains a challenge. Acute appendicitis, although not as common in African children, often presents rather late with up to 50% of children presenting with perforation and other complications, and mortality is approximately 4% is some settings. Pyomyositis and necrotizing fasciitis are the more common serious soft-tissue infections, but early recognition and prompt treatment should minimize the occasional mortality. Though common in Africa, the exact impact of human immunodeficiency virus infection on the spectrum and severity of surgical infection in African children is not clear, but it may well worsen the course of infection in these patients.

Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer)

We report a case of under treated necrotizing fasciitis (NF) in a 65-year-old woman with diabetes misdiagnosed as Mycobacterium ulcerans infection. She came to the Institut Médical Evangélique (IME) with an extensive painful edematous ulcerated lesion on the dorsum of the right foot and ankle. The diagnosis of Buruli ulcer (BU) was based initially on clinical findings and place of residence (Songololo Territory, the largest known focus of BU in Bas-Congo province). Tissue specimens gave negative results for acid-fast bacilli (AFB), culture, and polymerase chain reaction (PCR) for M. ulcerans. Histopathologic analysis revealed marked necrosis of the lower dermis and subcutaneous tissue. No AFB was found. Later, scattered foci of intracellular gram-positive cocci typical of streptococci were seen. Clinicopathologic correlation of these findings strongly supported the diagnosis of NF. This patient shows the difficulties that may be encountered even in known endemic areas in recognizing BU cases purely on clinical findings.