Necrotizing fasciitis

The Thousand Faces of Invasive Group A Streptococcal Infections: Update on Epidemiology, Symptoms, and Therapy

Invasive infections caused by Streptococcus pyogfenes (iGAS), commonly known as Group A Streptococcus, represent a significant public health concern due to their potential for rapid progression and life-threatening complications. Epidemiologically, invasive GAS infections exhibit a diverse global distribution, affecting individuals of all ages with varying predisposing factors. The pathogenesis of invasive GAS involves an array of virulence factors that contribute to tissue invasion, immune evasion, and systemic dissemination. In pediatrics, in the last few years, an increase in iGAS infections has been reported worldwide becoming a challenging disease to diagnose and treat promptly. This review highlights the current knowledge on pathogenesis, clinical presentations, and therapeutic approaches for iGAS in children.

Pediatric Necrotizing Fasciitis

Necrotizing fasciitis (NF) is a rapidly progressing bacterial infection of the subcutaneous tissue that can be lifethreatening. Without prompt diagnosis and treatment, it can lead to septic shock, organ failure, and death. Due to the rarity of this disease in the pediatric population and the fact that initial symptoms are frequently nonspecific, NF in children is often misdiagnosed as cellulitis, which delays the correct treatment. Physicians must maintain a high index of suspicion and keep NF in mind because rapid surgical debridement is necessary to reduce morbidity and mortality. The purpose of this article is to better characterize what is currently known about NF within the pediatric population. In this article, the microbiology, pathophysiology, clinical manifestations, diagnosis, and treatment of pediatric NF are reviewed, and key differences between adult and pediatric NF are highlighted. Key Concepts•One must keep Necrotizing Fasciitis in mind when dealing with soft tissue infections.•A common symptom is a disproportionate level of pain for what can appear to be cellulitis.•Prompt treatment must include early, thorough, and frequently multiple debridements.•As a result of low incidences, collaborative multiple-center studies are needed to improve our level of understanding.

A rare case of necrotizing fasciitis after early infant male circumcision

Even though circumcision is low-risk, complications may occur, necessitating careful management. Here, we describe a 5-month-and-28-day-old infant who developed necrotizing fasciitis following Plastibell circumcision. This report emphasizes that clinicians should use standard equipment and appropriate-sized rings to prevent these unusual complications following circumcision.

Cultured Epidermal Autograft for Total Scalp Reconstruction in a Neonate Following Necrotizing Fasciitis

Necrotizing fasciitis in the pediatric population is a particularly difficult diagnostic and management challenge. Options for soft tissue reconstruction of wounds following surgical debridement have been historically limited, yet recent advancements in bioengineered tissue and matrices have introduced alternative methods of treatment for these patients. We present a case of neonatal necrotizing fasciitis of the scalp requiring full-thickness surgical debridement, which was successfully reconstructed using Epicel cultured epidermal autograft (CEA). A 4-day-old female neonate (gestational age 40 weeks) presented with scalp erythema, blistering, and sepsis following peripartum fetal scalp electrode monitoring. She underwent surgical excision of the scalp to healthy bleeding tissue resulting in a defect of approximately 97% of the scalp, measuring 18 × 19 cm including 4 × 3.5 cm of exposed bone at the occiput. Initial provisional coverage of the defect was obtained with Integra collagen matrix bilayer dressing to stimulate granulation over exposed bone. Concurrently, a 2 × 4-cm excisional biopsy of the left groin skin was obtained for CEA in vitro expansion over 21 days. Then, autograft sheets were applied to achieve total scalp coverage. Clinical assessments at 1 week, 1 month, and 2 months postoperatively exhibited, approximately, 60% take, 80% take, and 90% take, respectively. Scalp involvement in neonatal necrotizing infections is a notably rare presentation as surmised by our review of the literature, and to our knowledge, this is the first report on the use of Integra and CEA for near-total neonatal scalp coverage.

Polymicrobial Necrotizing Fasciitis in a Dog: The Involvement of Macrococcus caseolyticus, Proteus mirabilis, and Escherichia coli

A male mixed breed dog was presented with two large wounds, extending the epidermis, dermis, and fascia: one at the dorsum of the thoracolumbar region and the other at the lumbosacral area. Lesions had extended inconspicuously to the dorsum of thorax affecting a large area, which showed regions with necrotic and crepitating foci after shaving. Based on histopathological and bacterial culture examinations, polymicrobial necrotizing fasciitis (NF) was diagnosed. Using the Bruker MALDI Biotyper identification technique, Macrococcus caseolyticus, Proteus mirabilis, and Escherichia coli were identified. Hitherto, there is no report on these bacteria linking them simultaneously to NF in a dog. In addition, the authors highlight other microbes associated with NF in humans and animals.

Pyoderma gangrenosum underrepresentation in non-dermatological literature

Background

Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).

Methods

We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).

Results

Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.

Conclusions

There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.

Necrotizing Soft Tissue Infections: A Focused Review of Pathophysiology, Diagnosis, Operative Management, Antimicrobial Therapy, and Pediatrics

Background: Necrotizing fasciitis is a major health problem throughout the world. The purpose of this review is to assist providers with the care of these patients through a better understanding of the pathophysiology and management options. Methods: This is a collaborative review of the literature between members of the Surgical Infection Society of North America and World Society of Emergency Surgery. Results: Necrotizing fasciitis continues to be difficult to manage with the mainstay being early diagnosis and surgical intervention. Recognition of at-risk populations assists with the initiation of treatment, thereby impacting outcomes. Conclusions: Although there are some additional treatment strategies available, surgical debridement and antimicrobial therapy are central to the successful eradication of the disease process.

A case of streptococcus necrotizing fasciitis secondary to acute tonsillitis and review of literatures

Necrotizing fasciitis, officially named by Wilson in 1952, was a rare potentially life-threatening necrotizing soft tissue infections disease. The main lesions showed subcutaneous fat and fascia layer in progressive necrosis, generally not involving muscles. It was characterized by acute onset, rapid progress, and dangerous condition, often accompanied by systemic toxin shock, which was a relatively rare clinical acute critical disease with high mortality rate. Necrotizing fasciitis is a rare but clinical critical disease. The overall incidence of necrotizing fasciitis is approximately 0.04 cases per 1000 persons in the United States, the 30-day mortality is 27%, and necrotizing fasciitis–related mortality in Asian region is about 28%. Streptococcus pyogenes (group A streptococcus) are human-specific pathogens that can cause upper respiratory tract infection such as tonsillitis, associated with post-infection diseases such as rheumatic fever, and also can induce severe invasive diseases such as necrotizing fasciitis and streptococcus toxin shock syndrome. This article reports a case of streptococcus necrotizing fasciitis secondary to suppurative tonsillitis, which was seldom reported before and our successful management with delayed debridement. This study was anonymous and was approved by the local Research Ethics Committee. Informed consent was obtained from the patient.

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.

Tales from the Night:: Emergency MR Imaging in Pediatric Patients after Hours

Overnight in-house radiology has rapidly become an important part of contemporary practice models, and is increasingly the norm in pediatric radiology. MR imaging is an indispensable first-line and problem-solving tool in the pediatric population. This has led to increasingly complex MR imaging being performed "after hours" on pediatric patients. This article reviews the factors that have led to widespread overnight subspecialty radiology and the associated challenges for overnight radiologists, and provides an overview of up-to-date imaging techniques and imaging findings of the most common indications for emergent MR imaging in the pediatric population.

Necrotizing Fasciitis: An Overview and 2 Illustrative Cases

Necrotizing fasciitis is the generic term for a series of progressive gangrenous infections of the skin and subcutaneous tissues. Typically, necrotizing fasciitis start with an, often small, infected lesion with atypical symptoms, which then quickly develops into a rapidly spreading, massive infection. The primary therapy is excision of all necrotic tissue in combination with treatment of systemic symptoms such as shock. The defects resulting from rigorous excision are often very large. Once they are clean, they require closure with an autograft. This article reviews the symptoms and treatment of necrotizing fasciitis. In addition, it illustrates, with 2 cases, how a hyaluronic-based extracellular matrix can be used to "fill in" with neodermis for the lost dermis and can create a wound bed most suitable for grafting.

Fulminant Staphylococcal Infections

Fulminant staphylococcal infection indicates an explosive, intense, and severe infection occurring in a patient whose previous condition and antecedent would never have caused any anticipation of life-threatening development. This includes necrotizing pneumonia, necrotizing fasciitis, and to some extent toxic shock syndrome and infective endocarditis. In the three former diseases, toxin production plays a major role whereas in the latter (fulminant presentation of infective endocarditis), association with any particular toxinic profile has never been demonstrated. This article reviews the clinical, pathophysiological, and therapeutic aspects of these diseases.

Presenting features of extremity necrotizing fasciitis in the pediatric patient: a case-control analysis

This analysis sought to develop a tool for early differentiation between pediatric necrotizing fasciitis (NF) of the extremity and more benign infection. All diagnoses of extremity NF, cellulitis, and abscess from a single institution from 2009 to 2015 were included. Vitals and laboratory values were compared between cohorts using analysis of variance and decision tree analysis. NF was associated with thrombocytopenia, hyperthermia, tachycardia, and tachypnea. Decision tree analysis identified C-reactive protein more than 7.0 to be 100% sensitive and 95.7% specific for differentiating NF from cellulitis or abscess. The results offer quantitative support for clinical suspicion of NF in the evaluation of pediatric extremity infection.

Advances in pharmacotherapeutic management of common skin diseases in neonates and infants

INTRODUCTION

neonatal and infantile skin diseases are frequently encountered in the clinical practice and represent worldwide a socioeconomic issue. They encompass a wide range of acquired or congenital conditions, including infections, vascular lesions and inflammatory diseases and can present with different degrees of severity, leading in some cases to dramatic complications. Areas covered: In this paper we report the most recent evidences on the management of some common skin diseases in neonates and infants. Hemangiomas, viral, fungal and bacterial infections, omphalitis, atopic and seborrhoeic dermatitis, napkin disease will be treated and discussed. Expert opinion: The majority of the dermatologic alterations in neonates are physiological, transient and do not require any treatment, thus the parents can be reassured about the good prognosis. However, in some cases, serious conditions must be excluded. In particular neonatal and infantile infections should be promptly recognized and properly managed, to avoid severe complications. The therapeutic options include traditional and, although few, innovative medical treatments, which will be carefully taken into consideration by the expert Dermatologists and Paediatricians.

Necrotizing Fasciitis of the Abdominal Wall in a Premature Infant: A Case Study

We present a first report of necrotizing fasciitis of the abdominal wall in a 23-day-of-age, former 32-week-gestation premature infant. She was successfully treated with antibiotics without the need for initial debridement. After reviewing the etiology of necrotizing fasciitis, we discuss the unique aspects of this case, including the noninvasive approach to initial treatment, which we consider significantly contributed to her survival.

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.

Clostridial Infections in Children: Spectrum and Management

Clostridia can cause unique histotoxic syndromes produced by specific toxins (e.g., gas gangrene and food poisoning) as well as non-syndromic infections (e.g., abscess, local infections, and blood born infection). Clostridia can also be recovered from various body sites as part of polymicrobial aerobic-anaerobic infection. These include intra-abdominal (peritonitis and abscess), biliary tract, female genital tract, abscess (rectal area and oropharyngeal), pleuropulmonary, central nervous system, and skin and soft-tissue infections. Clostridia were recovered from children with bacteremia of gastrointestinal origin, necrotizing enterocolitis, and sickle cell disease. They have also been isolated in acute and chronic otitis media, chronic sinusitis and mastoiditis, peritonsillar abscesses, and neonatal conjunctivitis. Early and aggressive surgical debridement, decompression, and drainage of affected tissues are critical to successful outcome of histotoxic infections. Effective antimicrobials include penicillin, clindamycin, chloramphenicol, third-generation cephalosporins, carbapenems, and vancomycin.

Ocular necrotizing fasciitis due to Pseudomonas aeruginosa in a non-neutropenic patient

Eyelid necrosis is a very rare disease, usually secondary to trauma or infections. Pseudomonas aeruginosa (PA) eyelid necrosis remains principally a clinical diagnosis and it is often missed early in its presentation because of the difficulty in differentiating it from more common soft tissue infections. However, when the diagnosis is made we must act quickly due to the fatal evolution if not handled properly. We present the case of a non-neutropenic 53-year-old male patient with a history of alcoholism, smoking habit and lung cancer under chemotherapy treatment who developed ocular necrotizing fasciitis due to PA with perforation of his left eye and severe bilateral sclera ischemia despite intensive antibiotic treatment and surgical debridement.

Necrotizing fasciitis

Necrotizing fasciitis (NF) is among the most challenging surgical infections faced by a surgeon. The difficulty in managing this entity is due to a combination of difficulty in diagnosis, and also of early as well as late management. For the patient, such a diagnosis means prolonged hospital stay, painful dressings, an extended recovery, and in some unfortunate cases even loss of limb or life. Necrotizing fasciitis is a fairly common condition in surgical practice in the Indian context resulting in a fairly large body of clinical experience. This article reviews literature on MEDLINE with the key words "necrotizing," "fasciitis," and "necrotizing infections" from 1970, as well as from articles cross referenced therein. The authors attempt to draw comparisons to their own experience in managing this condition to give an Indian perspective to the condition.

Fatal Necrotizing Fasciitis in a Child following a Blunt Chest Trauma

Necrotizing fasciitis is a serious soft tissue infection rarely occurring in children after blunt trauma. Due to its high morbidity and mortality rates, a high index of suspicion is necessary for prompt diagnosis and treatment. We describe a 6-year-old Costa Rican girl who died secondary to multiple complications following a posttraumatic necrotizing fasciitis.

Clostridial infection in children

A survey of the isolation of Clostridium spp. from 1543 specimens sent to anaerobic microbiology laboratories revealed 113 isolates from 107 specimens (7.0% of all specimens) from 96 children. The isolates comprised 43 (38%) unidentified Clostridium spp., 37 (33%) C. perfringens, 13 (12%) C. ramosum, five (4%) C. innocuum, six (5%) C. botulinum, three (3%) C. difficile, two (2%) C. butyricum, and one isolate each of C. bifermentans, C. clostridiiforme, C. limosum and C. paraputrificum. Most clostridial isolates were from abscesses (38), peritonitis (26), bacteraemia (10), and chronic otitis media (7). Predisposing or underlying conditions were present in 31 (32%) cases. These were immunodeficiency (12), malignancy (9), diabetes (7), trauma (7), presence of a foreign body (6) and previous surgery (6). The clostridia were the only bacterial isolates in 14 (15%) cases; 82 (85%) cases had mixed infection. The species most commonly isolated with clostridia were anaerobic cocci (57); Bacteroides spp. (B. fragilis group) (50), Escherichia coli (22), pigmented Prevotella or Porphyromonas spp. (18) and Fusobacterium spp. (10). Most Bacteroides and Escherichia coli isolates with clostridia were from abdominal infections and skin and soft tissue infections adjacent to the rectal area; most pigmented Prevotella and Porphyromonas isolates were from oropharyngeal, pulmonary, and head and neck sites. Antimicrobial therapy was given to all patients, in conjunction with surgical drainage in 34 (35%). Only two patients died. These data illustrate the importance of Clostridium spp. in paediatric infections.