Intravenous immunoglobulin in necrotizing fasciitis - A case report and review of recent literature

A case of necrotizing fasciitis initially misdiagnosed as cellulitis

INTRODUCTION AND IMPORTANCE

Necrotizing Fasciitis (NF) is a life-threatening, rapidly progressive infection of the skin and underlying soft tissues. Bacterial pathogens induce a toxic-shock reaction that reduces vascular flow, causing thrombosis, sepsis, and tissue necrosis. Treatment consists of immediate IV antibiotics and oftentimes surgical intervention. We present a case of acute NF that was misdiagnosed as cellulitis.

CASE PRESENTATION

A 17-year-old male was transferred to an emergency department from a rural hospital for further management of right lower extremity cellulitis and suspected sepsis. On examination, there was an ulcerated lesion on his right lower leg. Within 4 h, the patient underwent fasciotomy and debridement. The patient was hospitalized for 10 days, received a 3-week-course of Cefazolin, and underwent a meshed split-thickness skin graft. By the end of his hospital stay, he showed significant clinical improvement.

CLINICAL DISCUSSION

Misdiagnosis of NF will almost always lead to a poorer prognosis. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to differentiate NF from other soft tissue infections. Yet, other diagnostic clues such as presentation or pain out of proportion to physical findings may be more relevant clinical indicators for a NF diagnosis. Moreover, though imaging findings of NF may be relevant, surgical fascial examination must not be delayed for the purpose of imaging. It is also important to note that cellulitis and NF do share a disease spectrum.

CONCLUSION

A life-threatening NF infection may seem to be a benign-appearing case of cellulitis, and thus early detection is vital.

A parotid abscess out of control resulting in craniocervical necrotising fasciitis in the context of diabetes mellitus-a case report and review of the literature

Background

Necrotising fasciitis is an aggressive life-threatening infective process rarely making an appearance in the head and neck region and its development secondary to parotid abscess is exceptionally rare and scarcely reported in the literature. This case report serves to guide otolaryngologists with respect to its recognition and offers an alternative approach to craniocervical necrotising fasciitis with multiple neck explorations, use of antimicrobial impregnated packing enabling delayed reconstruction with lower morbidity.

Case Description

A 76-year-old female with a body mass index of 36.2 kg/m2 and a 30-year history of poorly controlled type 2 diabetes mellitus (HbA1c 91 mmol/moL), presented to the outpatient otolaryngology clinic with right sided parotid mass with minimal erythema, hyperglycaemia (19.2 mmol/L) and no cranial neuropathies. However, the aggressive nature of the parotid abscess triggered by group A streptococcus and Staphylococcus epidermidis led to sepsis and extensive non-odontogenic necrotising fasciitis involving the lateral neck mandating multiple surgical debridement and neck explorations, prolonged intravenous antibiotics with interval definitive reconstruction. A cervicofacial rotational sternocleidomastoid flap was utilised to conceal the defect with patient experiencing a remarkable recovery. The patient's immunosuppressive state from poorly controlled diabetes mellitus and multi-lineage cytopenia is likely to have contributed to a prolonged recovery.

Conclusions

This case report highlights the significance of repeat explorations and the need to give time for tissue healing as it unlocks options for reconstruction and reduce overall patient morbidity. Bismuth iodoform paraffin paste packing is a valuable tool with this case demonstrating its use an antiseptic and haemostatic agent in necrotising fasciitis and its ability to create an atmosphere to enable tissue healing minimising need for large-scale reconstructions. The absence of crepitus should not discourage the treating clinician from suspecting necrotising fasciitis of the neck. To limit successive cases, early prevention through aggressive control of predisposing systemic conditions including diabetes mellitus is needed. Moreover, when aggressive infections arise, the clinician should investigate for contributing systemic conditions.

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

Necrotizing fasciitis a review

Necrotizing fasciitis is an uncommon, rapidly progressive, often aggressive bacterial infection that causes extensive necrosis of the subcutaneous tissue and fascia, relatively sparing the muscle and skin tissues. Rapid diagnosis of the disease is mandatory because the delay in initiation of aggressive treatment negatively influences the outcome. Specific clinical signs may not be always present, which makes an accurate and timely diagnosis difficult. Based on the literature, this article presents a review of the historical background, etiology, pathophysiology, clinical findings, diagnostic strategies, treatment and prognosis of the disease.

A Predictive Model of Antibody Binding in the Presence of IgG-Interacting Bacterial Surface Proteins

Many bacteria can interfere with how antibodies bind to their surfaces. This bacterial antibody targeting makes it challenging to predict the immunological function of bacteria-associated antibodies. The M and M-like proteins of group A streptococci (GAS) exhibit IgGFc-binding regions, which they use to reverse IgG binding orientation depending on the host environment. Unraveling the mechanism behind these binding characteristics may identify conditions under which bound IgG can drive an efficient immune response. Here, we have developed a biophysical model for describing these complex protein-antibody interactions. We show how the model can be used as a tool for studying the binding behavior of various IgG samples to M protein by performing in silico simulations and correlating this data with experimental measurements. Besides its use for mechanistic understanding, this model could potentially be used as a tool to aid in the development of antibody treatments. We illustrate this by simulating how IgG binding to GAS in serum is altered as specified amounts of monoclonal or pooled IgG is added. Phagocytosis experiments link this altered antibody binding to a physiological function and demonstrate that it is possible to predict the effect of an IgG treatment with our model. Our study gives a mechanistic understanding of bacterial antibody targeting and provides a tool for predicting the effect of antibody treatments in the presence of bacteria with IgG-modulating surface proteins.

Necrotising fasciitis in the North East of Scotland: a 10-year retrospective review

INTRODUCTION

Necrotising fasciitis is a life-threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of surgical debridement, antibiotics and intensive care support. All cases of necrotising fasciitis in 10 years in the North East of Scotland were reviewed to investigate and improve patient care.

METHODS

Cases between August 2006 and February 2016 were reviewed using case notes and electronic hospital records. Data including mode of admission, clinical observations, investigations, operative interventions, microbiological and clinical outcomes was collected and reviewed. Analysis required multidisciplinary input including microbiology, infectious disease, trauma and orthopaedics, plastic surgery and intensive care teams.

RESULTS

A total of 36 cases were identified. The mean laboratory risk indicator for necrotising fasciitis (LRINEC) score was 7 and 86% of patients fulfilled the criteria for necrotising fasciitis. Patients were commonly haemodynamically stable upon admission but deteriorated rapidly; 36% of patients had a temperature of over 37.5 degrees C on initial observations; 29/36 patients were discharged, 6 patients died acutely (acute mortality rate of 17%); 18/31 of cases were polymicrobial with Streptococcus pyogenes, the common organism. Six amputations or disarticulations were performed from a total of 82 operations in this group, with radical debridement the usual primary operation. The mean time to theatre was 3.54 hours. Highly elevated admission respiratory rate (50 breaths/minute) was associated with increased mortality.

CONCLUSIONS

Necrotising fasciitis presents subtly and carries significant morbidity and mortality. A high index of suspicion allows early diagnosis and intervention. We believe that a pan-specialty approach is the cornerstone for good outcomes.

Reversing Autoimmunity Combination of Rituximab and Intravenous Immunoglobulin

In this concept paper, the authors present a unique and novel protocol to treat autoimmune diseases that may have the potential to reverse autoimmunity. It uses a combination of B cell depletion therapy (BDT), specifically rituximab (RTX) and intravenous immunoglobulin (IVIg), based on a specifically designed protocol (Ahmed Protocol). Twelve infusions of RTX are given in 6–14 months. Once the CD20⁺ B cells are depleted from the peripheral blood, IVIg is given monthly until B cells repopulation occurs. Six additional cycles are given to end the protocol. During the stages of B cell depletion, repopulation and after clinical recovery, IVIg is continued. Along with clinical recovery, significant reduction and eventual disappearance of pathogenic autoantibody occurs. Administration of IVIg in the post-clinical period is a crucial part of this protocol. This combination reduces and may eventually significantly eliminates inflammation in the microenvironment and facilitates restoring immune balance. Consequently, the process of autoimmunity and the phenomenon that lead to autoimmune disease are arrested, and a sustained and prolonged disease and drug-free remission is achieved. Data from seven published studies, in which this combination protocol was used, are presented. It is known that BDT does not affect check points. IVIg has functions that mimic checkpoints. Hence, when inflammation is reduced and the microenvironment is favorable, IVIg may restore tolerance. The authors provide relevant information, molecular mechanism of action of BDT, IVIg, autoimmunity, and autoimmune diseases. The focus of the manuscript is providing an explanation, using the current literature, to demonstrate possible pathways, used by the combination of BDT and IVIg in providing sustained, long-term, drug-free remissions of autoimmune diseases, and thus reversing autoimmunity, albeit for the duration of the observation.

A case of periorbital necrotizing fasciitis rapidly progressing to severe multiorgan failure

Periorbital necrotizing fasciitis (PNF) is a severe suppurative infection of the subcutaneous tissue and underlying fascia of the periorbital region. Typically, the course of PNF is milder and has a better prognosis than that of necrotizing fasciitis in other parts of the body. As such, this disease is thought to be associated with a significantly smaller risk of morbidity and mortality. Nevertheless, it is a rare and devastating condition that can lead to disfigurement, blindness and death. Early recognition is critical to improved patient outcomes. Here, we describe a case of PNF in a 60-year-old male that rapidly progressed to widespread systemic involvement and severe multiorgan failure requiring ventilatory, cardiovascular and renal support. Treatment included broad-spectrum antibiotics, intravenous immunoglobulin and surgical debridement. This case highlights the life-threatening nature of PNF, as demonstrated by rapid progression to multiorgan dysfunction and the need of an urgent surgical intervention.

Necrotizing soft tissue infection: clinical characteristics and outcomes at a reconstructive center in Jilin Province

BACKGROUND

To investigate the clinical characteristics and treatment outcomes in necrotizing fasciitis (NF) patients in a reconstructive unit in northeastern China.

METHODS

Medical records of patients diagnosed with and treated for NF in the extremities from November 2013 to December 2016 were retrospectively reviewed. Demographic data, clinical presentation, duration of signs and symptoms, location of infection, predisposing factors, causative microbiological organisms, laboratory risk indicator for necrotizing fasciitis (LRINEC) score, number of surgical debridements, length of hospital stay, treatments, and outcomes were recorded.

RESULTS

A total of 39 consecutive patients were treated for severe NF (32 male and 7 female). Diabetes mellitus and blunt trauma were the most common risk factors (13 and 9 cases, respectively). The positive predictive value of the LRINEC score in NF diagnosis was 46.2%. Mean duration of signs and symptoms was 4.6 days. Staphylococcus aureus was the most commonly isolated bacteria (20 cases). All patients underwent their first debridement within 12 h of presentation (mean, 4.6 h). Mean number of surgical treatments was 2.8 (range, 2-5) per patient, including debridements. All patients survived, and mean length of hospital stay was 30.81 (range, 21-43) days. Three patients underwent limb amputation.

CONCLUSIONS

In our clinical experience, early detection and aggressive debridement are the cornerstones of NF treatment. Antibiotic therapy and intensive care support is essential in severe cases of NF. Anaerobic tissue culture and frozen section biopsy could be adopted as routine tests for diagnosis and decision-making in NF. These findings should inform clinical decisions about the treatment of individual patients with NF.

Validation of a clinical trial composite endpoint for patients with necrotizing soft tissue infections

OBJECTIVE

Our objective was to develop and validate a composite endpoint for patients with necrotizing soft tissue infections that incorporates: local tissue injury, systemic organ dysfunction, and mortality.

METHODS

The Necrotizing Infection Clinical Composite Endpoint (NICCE) was defined as follows:(i) alive at day 28, (ii) three or less debridements before day 14, (iii) no amputation beyond first debridement, (iv) modified sequential organ failure assessment score score (mSOFA) at day 14 ≤ 1. To be considered a success, all individual criteria must be met. Several data sets were used to assess validity: (i) a retrospective data set of 198 patients treated during 2013 at 12 US trauma centers; (ii) a subset with high disease acuity, admission mSOFA score of 3 or higher (n = 69); and (iii) 40 patients from a multicenter, phase 2 randomized trial of a CD28 immunomodulator (AB103). Clinical success based on each parameter and the composite score was assessed.

RESULTS

Using the retrospective data set for all patients and those with high disease severity (respectively), survival rates were 92% and 84%; day 14 mSOFA 1 or lower score was 69% and 51%; three or less debridements was 84% and 77%; and no subsequent amputations were 96% and 94%. Overall, the percent meeting all success criteria for NICCE was 58% (all patients) and 33% (mSOFA > 3). NICCE success was also associated with reduced utilization of health care resources, intensive care unit-free days were median (interquartile range) of 25.3 (21.9-28) and 19.6 (4.3-25.1) days (one-sided Wilcoxon p < 0.001) and ventilator-free days were 28 (26-28) versus 25 (14-28) (p < 0.001) for NICCE success versus failure, respectively. Using the phase 2 data set, the treated group (0.5 mg/kg, n = 15) demonstrated a NICCE success rate of 73.3% versus 40% for placebo (n = 10).

CONCLUSION

These data demonstrate internal consistency of the components and face and criterion validity of the NICCE endpoint. NICCE offers an opportunity to demonstrate a clinically relevant treatment effect for patients enrolled in clinical trials for necrotizing soft tissue infection.

LEVEL OF EVIDENCE

Prognostic/Epidemiological, level III; Therapeutic, level IV.

Epidemiology and Outcomes of Hospitalized Children With Necrotizing Soft-Tissue Infections

OBJECTIVE

The purpose of this study was to evaluate the epidemiology and outcome of hospitalized children with a diagnosis of necrotizing soft-tissue infections (NSTIs).

METHODS

Demographic and outcome data of children 1 month to 18 years of age with a diagnosis of NSTI (International Classification of Diseases, 9th revision diagnosis codes 728.86 and 729.4) were extracted from the Kids' Inpatient Database 2009 and 2012. Univariate and multivariate analyses were done to determine the factors affecting mortality. The sample data were weighted to get national estimates.

RESULTS

A total of 446 children with NSTI (prevalence of 1.12/10,000 discharges) were included. Males comprised 54%. The median age was 10 (interquartile range 4-16) years. The mortality rate was 6%. In addition, 29.3% of children with NSTI were discharged to either skilled nursing facilities or to home health care compared with 4.5% of children without NSTI (odds ratio 8.9; 95% confidence interval 7.3-10.9; P < 0001). A bacterial infection was reported in 72.1% of children. An infection with Staphylococcus, Streptococcus, Gram-negative bacteria, anaerobic bacteria, methicillin-resistant Staphylococcus areus and polymicrobia was present in 34.5%, 21.8%, 8.6%, 3.9%, 18.7% and 13.6% of cases, respectively. A compartment syndrome, severe sepsis/septic shock and toxic shock were documented in 4.4%, 22.2% and 3.2% of the cases, respectively. Severe sepsis/septic shock, the need for mechanical ventilation and Hispanic race were associated with increased mortality, whereas skin/muscle surgery was associated with lower mortality.

CONCLUSIONS

NSTI in children is associated with high morbidity. The mortality is higher with the presence of severe sepsis/septic shock and among Hispanics and lower with surgical intervention.

Association between cytokine response, the LRINEC score and outcome in patients with necrotising soft tissue infection: a multicentre, prospective study

Early assessment of necrotising soft tissue infection (NSTI) is challenging. Analysis of inflammatory markers could provide important information about disease severity and guide decision making. For this purpose, we investigated the association between cytokine levels and the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC)-score, disease severity and mortality in NSTI patients. In 159 patients, plasma was analysed for IL-1β, IL-6, IL-10 and TNF-α upon admission. The severity of NSTI was assessed by SAPS, SOFA score, septic shock, microbial aetiology, renal replacement therapy and amputation. We found no significant difference in cytokine levels according to a LRINEC- score above or below 6 (IL-1β: 3.0 vs. 1.3; IL-6: 607 vs. 289; IL-10: 38.4 vs. 38.8; TNF-α: 15.1 vs. 7.8 pg/mL, P > 0.05). Patients with β-haemolytic streptococcal infection had higher level of particularly IL-6. There was no difference in mortality between patients with a LRINEC-score above or below 6. In the adjusted analysis assessing 30-day mortality, the association was strongest for IL-1β (OR 3.86 [95% CI, 1.43-10.40], P = 0.008) and IL-10 (4.80 [1.67-13.78], P = 0.004). In conclusion, we found no significant association between the LRINEC-score and cytokine levels on admission. IL-6 was consistently associated with disease severity, whereas IL-1β had the strongest association with 30-day mortality.

Treatment of Staphylococcus aureus Infections

Staphylococcus aureus, although generally identified as a commensal, is also a common cause of human bacterial infections, including of the skin and other soft tissues, bones, bloodstream, and respiratory tract. The history of S. aureus treatment is marked by the development of resistance to each new class of antistaphylococcal antimicrobial drugs, including the penicillins, sulfonamides, tetracyclines, glycopeptides, and others, complicating therapy. S. aureus isolates identified in the 1960s were sometimes resistant to methicillin, a ß-lactam antimicrobial active initially against a majority S. aureus strains. These MRSA isolates, resistant to nearly all ß-lactam antimicrobials, were first largely confined to the health care environment and the patients who attended it. However, in the mid-1990s, new strains, known as community-associated (CA-) MRSA strains, emerged. CA-MRSA organisms, compared with health care-associated (HA-) MRSA strain types, are more often susceptible to multiple classes of non ß-lactam antimicrobials. While infections caused by methicillin-susceptible S. aureus (MSSA) strains are usually treated with drugs in the ß-lactam class, such as cephalosporins, oxacillin or nafcillin, MRSA infections are treated with drugs in other antimicrobial classes. The glycopeptide drug vancomycin, and in some countries teicoplanin, is the most common drug used to treat severe MRSA infections. There are now other classes of antimicrobials available to treat staphylococcal infections, including several that have been approved after 2009. The antimicrobial management of invasive and noninvasive S. aureus infections in the ambulatory and in-patient settings is the topic of this review. Also discussed are common adverse effects of antistaphylococcal antimicrobial agents, advantages of one agent over another for specific clinical syndromes, and the use of adjunctive therapies such as surgery and intravenous immunoglobulin. We have detailed considerations in the therapy of noninvasive and invasive S. aureus infections. This is followed by sections on specific clinical infectious syndromes including skin and soft tissue infections, bacteremia, endocarditis and intravascular infections, pneumonia, osteomyelitis and vertebral discitis, epidural abscess, septic arthritis, pyomyositis, mastitis, necrotizing fasciitis, orbital infections, endophthalmitis, parotitis, staphylococcal toxinoses, urogenital infections, and central nervous system infections.