Serial immunologic and histopathologic studies in the treatment of necrotizing fasciitis with combined immunodeficiency by a bovine thymic extract (thymostimulin)

Necrotizing fasciitis following rapidly deteriorating neonatal omphalitis with good initial presentation

Neonatal omphalitis is a postpartum infection of periumbilical superficial soft tissues that usually has a good prognosis in developed countries. In rare cases, it could progress to periumbilical necrotizing fasciitis (NF), which is an infection of the deep soft tissues, including muscle fascia, and has a high mortality rate. However, the signs and timing of developing NF secondary to omphalitis are unclear. We encountered a neonatal case of NF following omphalitis. In the initial days of the clinical course, general symptoms and condition of the patient were good, and abdominal physical findings were mild; however, the patient rapidly developed NF. The patient was successfully treated by emergent surgical debridement, broad-spectrum antibiotics, and intensive care. To determine the area of blood perfusion, we intravenously injected indocyanine green by intraoperative angiography, and then extensively removed necrotic and hypoperfused tissues. In neonatal omphalitis, the deterioration can suddenly occur despite good initial conditions; intensive monitoring should be required during the first few days of the clinical course.

Cutaneous and subcutaneous infections in newborns due to anaerobic bacteria

This review describes the microbiology and management of the major cutaneous and subcutaneous infections in newborns where anaerobic bacteria predominate: omphalitis, necrotizing fasciitis, breast abscess, and scalp infection following intrauterine fetal monitoring. The predominant bacteria known to cause these infections are group B streptococcus, group D enterococcus, group A streptococcus, Staphylococcus aureus, Enterobacteriaceae, and anaerobic bacteria. All of these agents can colonize or infect the mother and subsequently colonize or infect the fetus or newborn either intrauterinely or during the passage through the birth canal. Infections due to anaerobes are often polymicrobial, and include also aerobic and facultative bacteria. The anaerobes recovered from these infections are Bacteroided fragilis group, Fusobacterium spp., Peptostreptococcus spp. and Clostridium spp. Early recognition and effective medical and surgical therapy are essential to recovery. Managements of these infections include surgical debridement and drainage when appropriate as well as topical and systemic use of antimicrobial agents effective against both aerobic and anaerobic bacteria.

Neonatal necrotizing fasciitis: a report of three cases and review of the literature

OBJECTIVE

Necrotizing fasciitis (NF) is a predominantly adult disorder, with bacterial infection of the soft tissue. In children, it is relatively rare and has a fulminant course with a high mortality rate. In the neonate, most cases of NF are attributable to secondary infection of omphalitis, balanitis, mammitis, postoperative complications, and fetal monitoring. The objective of this communication is to report 3 cases of neonatal NF and provide a literature review of this disorder.

RESULTS

This review yielded 66 cases of neonatal NF. Only 3 cases were premature. There was no sex predilection and the condition rarely recurred. Several underlying conditions were identified that might have contributed to the development of neonatal NF. These included omphalitis in 47, mammitis in 5, balanitis in 4, fetal scalp monitoring in 2, necrotizing enterocolitis, immunodeficiency, bullous impetigo, and maternal mastitis in 1 patient each. The most common site of the initial involvement was the abdominal wall (n = 53), followed by the thorax (n = 7), back (n = 2), scalp (n = 2), and extremity (n = 2). The initial skin presentation ranged from minimal rash to erythema, edema, induration or cellulitis. The lesions subsequently spread rapidly. The overlying skin might later develop a violaceous discoloration, peau d'orange appearance, bullae, or necrosis. Crepitus was uncommon. Fever and tachycardia were frequent but not uniformly present. The leukocyte count of the peripheral blood was usually elevated with a shift to the left. Thrombocytopenia was noted in half of the cases. Hypocalcemia was rarely reported. Of the 53 wound cultures available for bacteriologic evaluation, 39 were polymicrobial, 13 were monomicrobial, and 1 was sterile. Blood culture was positive in only 20 cases (50%). Treatment modalities included the use of antibiotics, supportive care, surgical debridement, and drainage of the affected fascial planes. Two of the 6 cases who received hyperbaric oxygen therapy died. The overall mortality rate was 59% (39/66). In 12 cases, skin grafting was required because of poor granulation formation or large postoperative skin defects among the survivors.

CONCLUSION

Neonatal NF is an uncommon but often fatal bacterial infection of the skin, subcutaneous fat, superficial fascia, and deep fascia. It is characterized by marked tissue edema, rapid spread of inflammation, and signs of systemic toxicity. The wound cultures are predominantly polymicrobial and the location of initial involvement depends on the underlying etiologic factor. High index of suspicion, prompt aggressive surgery, appropriate antibiotics, and supportive care are the mainstays of management in the newborn infant with NF.

Immune dysfunction in the elderly: effect of thymic hormone administration on several in vivo and in vitro immune function parameters

The effects of short-term thymic hormone administration on age-associated immune function were evaluated. Two groups of individuals greater than 65 years of age were treated for 30 days with thymic extracts (TP1) or placebo; before and after this treatment a panel of in vitro and in vivo parameters was determined according to a very rigorous experimental protocol. In most individuals, TP1 treatment was associated with an improvement in cutaneous delayed-type response to PPD. Moreover, an increase in a circulating T cell subpopulation bearing the CD45R surface antigen ("virgin" T cells), and in NK cell cytotoxic activity was also observed in some subjects. Finally, lymphocyte responsiveness to PHA tended to increase, while no effect on lymphocyte ability to produce IL-2 following mitogen stimulation was observed. These findings suggest that TP1 treatment may influence age-related alterations in immune function parameters in some subjects.

Beneficial effects of the thymic hormone preparation thymostimulin in patients with defects in cell-mediated immunity and chronic purulent rhinosinusitis. A double-blind cross-over trial on improvements in monocyte polarization and clinical effects

Twenty patients with chronic purulent rhinosinusitis were treated with TP-1 (Serono; 1 mg/kg body weight), in a double-blind cross-over trial. TP-1 was administered by daily i.m. injections for the first 14 days followed by two injections/week for 6 further weeks. The patients were immunologically special in that they had defects in their cell-mediated immune system. Fourteen showed a decreased chemotactic responsiveness of their peripheral blood monocytes as measured in the polarization assay. This defective function can probably be ascribed to the presence in serum of low molecular weight factors (LMWFs; less than 25 kD). As reported earlier, this factor shows a structural homology to the envelope protein of murine and feline leukaemia virus (P15E). Thirteen patients showed a defective delayed-type hypersensitivity (DTH) skin test reactivity towards candidin and/or streptokinase-streptodornase (Sk/Sd) antigen, 14 had a defective MIF production from their peripheral blood lymphocytes towards candidin, Sk/Sd and/or Haemophilus influenzae antigen. Eighteen patients completed the TP-1 trial and showed clinical improvements: 12 out of 15 were feeling better during TP-1 therapy and the nasal mucosa showed on inspection absent mucopurulent secretion in 13 patients. Positive bacterial culture rates for the nose decreased from 14 out of 16 to five out of 15. Placebo treatment had no significant effects. The clinical improvements were accompanied by a better performance of the cell-mediated immune system; the most significant effects were recorded in the monocyte polarization assay. The suppressive P15E-like LMWFs in serum clearly decreased during TP-1 treatment. In vitro TP-1 neutralized the immunosuppressive effect of the LMWFs. The restoring effects of TP-1 on monocyte polarization and its neutralizing activity of P15E-like LMWFs could explain the beneficial effects of thymic hormone treatment reported in adults with clinical signs of immunodeficiency in the presence of a full T cell repertoire.

A comparative study on the immunological effects of bovine and porcine thymic extracts: induction of lymphoproliferative response and enhancement of interleukin-2, gamma-interferon and tumor necrotic factor production in vitro on cord blood lymphocytes

Forty samples of cord blood lymphocytes were isolated from 40 normal healthy full-term newborns. The initial 20 samples were used to determine the dose-response curve of three different thymic extracts (TP-1, bovine thymic extract; TG-15-I and TG-15-II, both porcine thymic extracts) and one of renal origin (KG-1) as a control of non-lymphoid organ extract, by measuring the E-rosette T cells. Results showed that E-rosette T cells increased significantly when the thymic extract concentration was increased to 12.5 micrograms/ml. However, there was no statistical difference between TP-1, TG-15-I and TG-15-II in the increase of E-rosette-forming cells. The remaining 20 samples were preincubated with 0, 12.5, 25 or 50 micrograms/ml of thymic extracts. It was observed that the lymphoproliferation, interleukin-2 (IL-2), gamma-interferon (IFN-gamma) and tumor necrotic factor (TNF) production were all significantly increased after thymic extract treatment. No statistical difference between these three thymic preparations in the stimulation of lymphoproliferative response was found. However, among the three thymic extracts, TP-1 appears to induce the highest amounts of IL-2, IFN-gamma and TNF. Of the TG-15-I and TG-15-II, the former stimulates higher IL-2 production whereas the latter enhances IFN-gamma and TNF production. The different immunostimulating effects and potencies that these three thymic extracts showed may reflect not only the species difference but also the difference in preparation procedures. Different components in these thymic extracts may be responsible for different biological activities. Results from these comparative studies may provide useful information in future clinical trials for the treatment of the primary immunodeficiency diseases according to their pathogenesis and may also indicate a possible beneficial effect of the combination of chemotherapy and thymic extracts.

Enhancement of interleukin-2 and gamma-interferon production in vitro on cord blood lymphocytes and in vivo on primary cellular immunodeficiency patients with thymic extract (thymostimulin)

Cord blood mononuclear cells (MNC) were isolated from 20 normal full-term newborns. These MNC were preincubated with either 50, 100, or 200 micrograms/ml Thymostimulin or without Thymostimulin. The interleukin-2 (IL-2) and gamma-interferon (gamma-IFN) production, cytotoxicity, and lymphoproliferation and IL-2 receptor (Tac) expression were all significantly increased after Thymostimulin treatment. For evaluation of the in vivo effect, two combined-immunodeficiency patients defective on the thymic level, one with progressive BCG infection, and one with DiGeorge syndrome were used. Before Thymostimulin treatment, the patient's MNC did not produce sufficient amounts of IL-2 and gamma-IFN. The cytotoxicity and lymphoproliferation were also low. After Thymostimulin treatment, the IL-2 and gamma-IFN production, cytotoxicity, and lymphoproliferative response were enhanced. These results suggest that Thymostimulin may be beneficial in the clinical treatment of primary cellular immunodeficiency. The improved immune reactivity including cytotoxicity and enhanced IL-2 and gamma-IFN production in the Thymostimulin treatment also indicates that there may be a beneficial effect on the combination of chemotherapy and Thymostimulin.