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Sánchez A, Robaina R, Pérez G, Cairoli E. Streptococcus pneumoniae necrotizing fasciitis in systemic lupus erythematosus. Lupus 2015; 25:423-6. [PMID: 26453662 DOI: 10.1177/0961203315611498] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/18/2015] [Indexed: 11/17/2022]
Abstract
Necrotizing fasciitis is a rapidly progressive destructive soft tissue infection with high mortality. Streptococcus pneumoniae as etiologic agent of necrotizing fasciitis is extremely unusual. The increased susceptibility to Streptococcus pneumoniae infection in patients with systemic lupus erythematosus is probably a multifactorial phenomenon. We report a case of a patient, a 36-year-old Caucasian female with 8-year history of systemic lupus erythematosus who presented a fatal Streptococcus pneumoniae necrotizing fasciitis. The role of computed tomography and the high performance of blood cultures for isolation of the causative microorganism are emphasized. Once diagnosis is suspected, empiric antibiotic treatment must be prescribed and prompt surgical exploration is mandatory.
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Affiliation(s)
- A Sánchez
- Unidad de Enfermedades Autoinmunes Sistémicas, Clínica Médica "C", Prof. Dr. Juan Alonso Bao, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - R Robaina
- Unidad de Enfermedades Autoinmunes Sistémicas, Clínica Médica "C", Prof. Dr. Juan Alonso Bao, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - G Pérez
- Unidad de Enfermedades Autoinmunes Sistémicas, Clínica Médica "C", Prof. Dr. Juan Alonso Bao, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - E Cairoli
- Unidad de Enfermedades Autoinmunes Sistémicas, Clínica Médica "C", Prof. Dr. Juan Alonso Bao, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
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Tung Chen Y, Isenberg D. Necrotising fasciitis in systemic lupus erythematosus: a case report and literature review. Lupus Sci Med 2014; 1:e000008. [PMID: 25396059 PMCID: PMC4225728 DOI: 10.1136/lupus-2014-000008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/13/2014] [Accepted: 04/22/2014] [Indexed: 11/04/2022]
Abstract
Necrotising fasciitis (NF) is a rare infection of the subcutaneous tissue, known to be rapidly progressive and potentially fatal. Patients with systemic lupus erythematosus (SLE) may be predisposed to this condition, and early clinical recognition can be difficult. We report a case of necrotising fasciitis in a 26-year-old woman with SLE. She presented with painful swelling of her left leg, then developed clinical features of septic shock. Emergency debridement was performed. Intraoperative findings revealed NF and cultures grew Pseudomonas aeruginosa. The patient survived after a lengthy hospital admission, following several further debridements complicated by recurrent chest sepsis and multiorgan failure. We also review and discuss the published cases of NF in SLE patients.
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Affiliation(s)
- Y Tung Chen
- Department of Internal Medicine , University and Polytechnic Hospital of la Fe , Valencia , Spain
| | - D Isenberg
- Department of Medicine , Centre for Rheumatology, University College of London , London , UK
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Navinan MR, Yudhishdran J, Kandeepan T, Kulatunga A. Necrotizing fasciitis--a diagnostic dilemma: two case reports. J Med Case Rep 2014; 8:229. [PMID: 24965382 PMCID: PMC4086700 DOI: 10.1186/1752-1947-8-229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/22/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Necrotizing soft tissue infections can affect various tissue planes. Although predisposing etiologies are many, they mostly center on impaired immunity occurring directly or indirectly and loss of integrity of protective barriers which predispose to infection. The nonspecific presentation may delay diagnosis and favor high mortality. Case presentation Two case vignettes are presented. The first patient, a 44-year-old healthy South Asian man with a history of repeated minor traumatic injury presented to a primary health care center with a swollen left lower limb. He was treated with antibiotics with an initial diagnosis of cellulitis. Because he deteriorated rapidly and additionally developed intestinal obstruction, he was transferred to our hospital which is a tertiary health care center for further evaluation and management. Prompt clinical diagnosis of necrotizing soft tissue infection was made and confirmed on magnetic resonance imaging as necrotizing fasciitis. Urgent debridement was done, but the already spread infection resulted in rapid clinical deterioration with resultant mortality. The second patient was a 35-year-old South Asian woman with systemic lupus erythematous receiving immunosuppressive therapy who developed left lower limb pain and fever. Medical attention was sought late as she came to the hospital after 4 days. Her condition deteriorated rapidly as she developed septic shock and died within 2 days. Conclusions Necrotizing fasciitis can be fatal when not recognized and without early intervention. Clinicians and surgeons alike should have a greater level of suspicion and appreciation for this uncommon yet lethal infection.
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Netzer G, Fuchs BD. Necrotizing fasciitis in a plaster-casted limb: case report. Am J Crit Care 2009; 18:288-7. [PMID: 19411589 DOI: 10.4037/ajcc2009363] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Casts may be associated with, and mask, serious life-threatening complications, including infection, compartment syndrome, and deep vein thrombosis with or without pulmonary embolism. A 43-year-old woman had necrotizing fasciitis associated with a closed-reduction casting of a tibial fracture. Her treatment highlights the importance of removing a cast and assessing the skin and tissue underneath for signs of infection in patients with suspected infection. Thorough assessment, early diagnosis, and early intervention in necrotizing fasciitis and sepsis are important to improve patients' outcomes.
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Affiliation(s)
- Giora Netzer
- Giora Netzer is an assistant professor in the Division of Pulmonary and Critical Care Medicine, and the Department of Epidemiology and Preventive Medicine at the University of Maryland. Barry D. Fuchs is an associate professor in the Division of Pulmonary and Critical Care Medicine, University of Pennsylvania School of Medicine, and director of the medical intensive care unit at the University of Pennsylvania Hospital
| | - Barry D. Fuchs
- Giora Netzer is an assistant professor in the Division of Pulmonary and Critical Care Medicine, and the Department of Epidemiology and Preventive Medicine at the University of Maryland. Barry D. Fuchs is an associate professor in the Division of Pulmonary and Critical Care Medicine, University of Pennsylvania School of Medicine, and director of the medical intensive care unit at the University of Pennsylvania Hospital
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Kamran M, Wachs J, Putterman C. Necrotizing Fasciitis in Systemic Lupus Erythematosus. Semin Arthritis Rheum 2008; 37:236-42. [PMID: 17570472 DOI: 10.1016/j.semarthrit.2007.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 03/13/2007] [Accepted: 04/16/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Necrotizing fasciitis (NF) is an uncommon infection of the subcutaneous tissue and superficial fascia. Any delay in treatment can lead to catastrophic results with high mortality. It is well known that patients with systemic lupus erythematosus (SLE) are at increased risk of infection, from the disease and/or its treatment. The objective of our study was to evaluate the presenting features of NF in SLE patients and to identify possible risk factors for this severe complication. METHODS We searched for patients with diagnoses of SLE and NF using a computerized patient database at Montefiore Medical Center (MMC), from 1996 to present. We also included patients from the MMC Lupus Clinic with these diagnoses (identified from paper records) from 1994 to present. Of a total of 449 patients with SLE that were followed during this time, 8 patients with NF were identified, and their records were reviewed. RESULTS Two of the 8 patients (25%) died during hospitalization. A third patient died within 2 months of hospital discharge. All 8 patients were receiving steroids at the time of diagnosis, and 7 of 8 had hypoalbuminemia and lymphopenia. Both patients who died in the hospital and the one patient who died within 2 months of her discharge had lupus nephritis. CONCLUSIONS NF is an uncommon infection, but one that must be recognized early if the outcome is to be favorable. This series of 8 cases of NF in SLE from a single institution suggests that heightened awareness is warranted, particularly among SLE patients who are immunosuppressed by virtue of their underlying disease, the therapy they require, or both.
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Affiliation(s)
- Mohammad Kamran
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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Abstract
Primary skin infections (ie, pyodermas) typically are initiated by some breach in the epidermis, resulting in infection by organisms, such as Streptococcus pyogenes and Staphylococcus aureus, that normally colonize the skin. Host-associated factors, such as immunosuppression, vasculopathy, neuropathy, or decreased lymphatic drainage, may predispose to skin infection. The clinical syndromes associated with skin infections are often characteristic and are defined most simplistically by anatomic distribution. Although often mild and self-limited, skin infections can be more aggressive and involve deeper structures, including fascia and muscle. This article discusses skin and soft tissue infections, including impetigo, hair follicle-associated infections (ie, folliculitis, furuncles, and carbuncles) erysipelas, cellulitis, necrotizing fasciitis, pyomyositis, septic bursitis, and tenosynovitis.
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Affiliation(s)
- Fred A Lopez
- Section of Infectious Diseases, Department of Internal Medicine, Louisiana State University Health Sciences Center, Box E7-17, 2020 Gravier Street, New Orleans, LA 70112, USA.
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Abstract
Necrotizing fasciitis is an uncommon but life-threatening complication in immunocompromised hosts. We reported four patients with rheumatic diseases complicated by necrotizing fasciitis and reviewed 14 others from literature search. Most patients were on corticosteroid treatment. Septic shock, disseminated intravascular coagulopathy and acute renal deterioration were common giving rise to an overall mortality rate of 27.8%. Septic arthritis may also complicate the condition. Statistical analysis on the series showed the lack of major surgical debridement as the only risk factor associated with increased mortality (RR 7.5, 95% CI 2.1-27.3, P = 0.01). Timely debridement of necrotic tissue is important for reducing mortality.
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MESH Headings
- Adult
- Aeromonas/isolation & purification
- Animals
- Anti-Bacterial Agents/therapeutic use
- Arthritis, Infectious/etiology
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/drug therapy
- Arthroplasty, Replacement, Hip
- Combined Modality Therapy
- Cyclophosphamide/adverse effects
- Cyclophosphamide/therapeutic use
- Debridement
- Disseminated Intravascular Coagulation/etiology
- Fasciitis, Necrotizing/drug therapy
- Fasciitis, Necrotizing/etiology
- Fasciitis, Necrotizing/surgery
- Fatal Outcome
- Female
- Femur Head Necrosis/chemically induced
- Femur Head Necrosis/surgery
- Fishes/microbiology
- Gram-Negative Bacterial Infections/drug therapy
- Gram-Negative Bacterial Infections/etiology
- Gram-Negative Bacterial Infections/surgery
- Humans
- Immunocompromised Host
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/drug therapy
- Middle Aged
- Prednisolone/adverse effects
- Prednisolone/therapeutic use
- Pseudomonas Infections/drug therapy
- Pseudomonas Infections/etiology
- Pseudomonas Infections/surgery
- Scleroderma, Diffuse/complications
- Scleroderma, Diffuse/drug therapy
- Shock, Septic/etiology
- Skin/injuries
- Skin Transplantation
- Streptococcal Infections/drug therapy
- Streptococcal Infections/etiology
- Streptococcal Infections/surgery
- Surgical Wound Infection/etiology
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Affiliation(s)
- M Y Mok
- University Department of Medicine, Queen Mary Hospital, Hong Kong.
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Isik A, Koca SS. Necrotizing fasciitis resulting from Streptococcus pneumoniae in recently diagnosed systemic lupus erythematosus case: a case report. Clin Rheumatol 2006; 26:999-1001. [PMID: 16525895 DOI: 10.1007/s10067-006-0234-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Revised: 01/31/2006] [Accepted: 01/31/2006] [Indexed: 11/29/2022]
Abstract
Systemic lupus erythematosus (SLE) is a systemic, autoimmune disease. SLE patients are prone to infections, and their hospital admissions and mortality are most commonly associated with infections. Necrotizing fasciitis (NF) is a rare, life-threatening infection of the subcutaneous tissue. In this report, NF associated with Streptococcus pneumoniae (SPN) that developed within hours and resulted in death is presented in a 46-year-old female case who was recently diagnosed as SLE and did not receive any medication (steroid, immunosuppressive, etc.) except for etodolac. This case shows that SLE can generate predisposition to NF, and SPN can play a role in NF etiology.
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Affiliation(s)
- A Isik
- Department of Rheumatology, Faculty of Medicine, Firat University, 23119, Elazig, Turkey
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Iglesias-Gamarra A, Mendez EA, Cuellar ML, Ponce de Leon JH, Jimenez C, Canãs C, Restrepo J, Peña M, Valle R, Espinoza LR. Poststreptococcal reactive arthritis in adults: long-term follow-up. Am J Med Sci 2001; 321:173-7. [PMID: 11269792 DOI: 10.1097/00000441-200103000-00003] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Poststreptococcal reactive arthritis (PSReA) is a recognized inflammatory articular syndrome that follows group A streptococcal infection in persons not fulfilling the Jones criteria for the diagnosis of acute rheumatic fever. Characteristic features include nonmigratory arthritis, lack of response to aspirin or nonsteroidal anti-inflammatory agents, and the presence of extra-articular manifestations, including vasculitis and glomerulonephritis. Whether or not patients with PSReA develop carditis is a point of contention. METHODS We analyzed the clinical features, laboratory findings, response to therapy, and outcome in patients diagnosed with PSReA between 1983 and 1998 and observed through April 2000. All patients were contacted, reexamined, and repeat antistreptolysin, rheumatoid factor, C3 and C4 complement components, and echocardiograms were performed. RESULTS Seventeen patients (4 men and 13 women) were included. All were of low socioeconomic status. All patients had acute severe arthritis that began shortly after a sore throat episode. Extra-articular involvement including tenosynovitis, vasculitis, and glomerulonephritis was relatively common. More importantly, none exhibited clinical and/or echocardiographic evidence of cardiac involvement. Longterm antibiotic therapy was not given. CONCLUSION Cardiac involvement did not occur in this group of patients with PSReA. Prolonged prophylactic antibiotic therapy may not be required for adult patients presenting with PSReA.
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