Case Presentation

Suzeth Lu Herrera, MD

Objectives
1. To present a case of a 3-year old child with necrotizing
fascitiis
2. To discuss the pathophysiology, diagnosis, differential
diagnosis and management of necrotizing fascitiis

General Data

JJ.O
3 years and 11 months old
female
Sta. Maria, Bulacan
Admitted: May 29, 2011

Chief Complaint
Ulcerative lesion
at the back

History of Present Illness

1 day PTA
apparently well
Night PTA
blue-blackish patch with central ulcer
erythematous patch 3cm
oozing of whitish discharges
left scapular area
NO pain
pain on palpation
No fever, vomiting
Cefalexin 45mg/kg/D and Mefenamic acid
No trauma or insect bite
Sought consult in this institution and was
admitted

Past Medical History

Diagnosed with Primary Kochs infection last March 2011
On the 4th month of treatment: Isoniazid and Rifampicin
? exposure
Previous hospitalization
Benign Febrile Seizure- June 2010

Family History
Father is known hypertensive
No known history of DM, Allergy, Asthma,
Malignancy

Genogram
57

32

JO

1m

Environmental and Social History

Brought up by uncle ( fathers side) since 1 month
old
Driver

Maternal and Birth History

Born to a 32-year old, G5P5 mother
Regular prenatal check-up at LHC,
Home-delivered, assisted by midwife, term, with good cry
and activity
No Newborn screening done

Nutritional History
Formula fed (S-26, Promil, Pediasure)
Supplementary feeding: 6 months old

Immunization

BCG
Hepatitis B X 3 doses
DPT X 3 doses
OPV X 3 doses
Measles 9 months

Growth and Development

At par with age

Smiled in response to voice at 1-month old

Holds head steady at 2-month old
Rolled over at 4-month old
Sat without support 6-month old
First tooth at 6 months lower central incisor
First word mama at 10 months old
Walked at 13 months

Review of Systems
Skin and Lymph blackish patch on left scapular area, no pain,
no LAD
HEENT - no headaches, conjunctivitis, visual problems, ear
infections, draining ears, cold and sore throats, oral thrush
Cardiac no cyanosis, chest pain
Respiratory no cough, difficulty of breathing
GI no diarrhea, constipation, vomiting, abdominal pain, with
good appetite
GU - no frequency, dysuria, hematuria, discharge
MSK - no joint pains or swelling, gait changes
NEURO: no seizures, no motor or sensory loss

PHYSICAL EXAMINATION
General Appearance: Awake, comfortable, NIRD
V/S: T: 36.70C HR: 104bpm RR: 28cpm BP: 100/70
Wt: 17.6 kg Ht: 96 cm
SKIN: 6X4cm necrotizing patch with central ulcer on left
scapular area
HEENT: anicteric sclera, pink palpebral conjunctivae, dry
lips, no tonsillopharyngeal congestion, no cervical
lymphadenopathies

CHEST AND LUNGS: symmetrical chest expansion, no

intercostal and subcostal retractions, clear breath sounds
HEART: no precordial bulging, with regular rate and rhythm,
apex beat at 5th intercostal space mid-calvicular area, no
murmur
ABDOMEN: full, soft, non tender, no organomegaly,
normoactive bowel sounds
GENITOURINARY: grossly female
EXTREMITIES: no deformities, equal and full pulses

Admitting Impression

Salient Features

3-year old
Female
Apparently well
Abrupt progression of skin changes from erythema to skin
necrosis with oozing of whitish fluid

Approach to Diagnosis
Rash/Skin lesion

Petechial/ purpuric rash

Macular/ Maculopapular rash
Vesicular/ Bullous rash
Urticarial rash
Distinctive rash

Consider:
CBC, plt
Coagulation studies
Blood CS
Wound GS and CS

Cellulitis Erysipelas Gas gangrene Purpura fulminanans Necrotizing fasciitis

NECROTIZING FASCIITIS
Necrotizing fasciitis is a rapidly progressive, deepseated bacterial infection of the subcutaneous soft
tissue that may involve any area of the body.
It often follows a fulminant course and has a high
mortality rate, ranging from 25% to 75%

 Causes: surgery, trauma, IV drug users, DM,

immunocompromise
A possible relationship between the use of
NSAIDs (as Ibuprofen) and development of
necrotizing fasciitis during varicella infections
have been shown

Sarah Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed. 2008.

Pathophysiology
Micobial invasion of SC
Release chemicals

External trauma
Direct spread

Tissue ischemia
Necrosis

Destruction of the nerves

Extensive tissue damage

Multi-organ failure and shock

Anesthesia

Symptoms/Signs Associated with Necrotizing Soft-Tissue Infection at the

Time of Admission
Percent of Percent of Percent of
Finding
Patients
Patients
Patients
(n=89)
(n =192)
(n=22)
Erythema

100

66

95

Pain or tenderness beyond margins

of erythema

98

73

95

Swelling
Crepitus or skin necrosis

92

75

86

13

31

Induration

12

45

Bullae

45

23

Fluctuance

11

Fever

53

32

Hypotension

18

11

41

Sarani B, Strong M, Pascual J, Schwab CW: Necrotizing fasciitis: current

concepts and review of the literature. J Am Coll Surg 2009, 208(2):279-88.

Clinical features of Necrotizing fasciitis as disease progress to clinical stages

Stage 1
(Early)
Tenderness to
palpation
(extending beyond
the apparent area of
skin involvement)
Erythema
Swelling
Warm to palpation

Stage II
(Intermediate)
Blister or bullae
formation
(serous fluid)
Skin fluctuance
Skin induration

Stage III
(Late)
Hemorrhagic bullae
Skin anesthesia
Crepitus
Skin necrosis with
dusky discoloration
progressing to
frank gangrene

Wong CH, Wang YS. The diagnosis of necrotizing fasciitis. Curr Opin Infect Dis. 2005;18(2):101106.

Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC)

A retrospective
analysis was
undertaken
to assess the
COURSE
IN
THE
WARD
Parameter
Points
applicability
and
usefulness
of
(LRINEC)
score
between
only
10%
to
40%
of
patients
st hospital stay
1
CRP
>150mg/L
4
January
December
2005 with the admission
Lab results:2002
will and
present
with classic
diagnosis of
necrotising
fasciitis3
history.
Leukocytosis
15-25X10
1
CBC:
Hgb:132
PT:
11.3
sec CBC, plt
Labs:
3
>25X10
2
Awake,
comfortable
Hct:
39
Control:
11.6
CXR
PAL
The
asigns
cut-off
score
area
of present
6,
of the LRINEC
hadwere
a
theWith
onlycommonest
that
were
in 50% ofscore
patients
0
V/S:
T:WBC
36.711.7
Blood
CS appeared
Hb
(g/dL)
1
involvement
in thespecificity
study
Activity:
100%
sensitivity
ofC80%,
of
67%,
a positive
predictive
erythema,
tenderness,
or11-13
edema
beyond
what
HR:
104bpm
<11 This
2 into
CS of of
wound
was
the
back
. ofainfection.
ofSeg:
57%
negative
predictive
value
86%
to value
be
the
confines
is GS,
in contradistinction
.40and
INR: 0.94
RR: 28cpmthe patients with proven necrotising
discharge
distinguishing
fasciitis
standard
teaching,
which
stresses
shock,
fever, and2 mental
Serum Na
<135
mmol/L
Lym:.50
100/70mmHg
PT, aPTT
fromBP:
those
with
soft
tissue infections.
status
changes
assevere
frequent
findings.
Mon:.06
PTT:
37.4
sec
Serum glucose
>10 mmol/L
1
Meds:
M. J. Holland. Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score
Sarani
B, necrotizing
Strong M, Pascual
J, Schwab
Necrotizing
fasciitis:
current
concepts
and Intensive
review of the
literature.
Am 588-592
Eos:
.03patch
Control:
34.2
(+)
with
Clindamycin
25mgkD
q 2009,
6h
inCW:
a tropical
tertiary
referral
centre.
Anaesth
Care
2009; J37:
Creatinineto patients
>141
umol/L
2Coll Surg
208(2):279-88.
centralPlatetet
ulcer on
Amikacin 15mgkD OD
ct:the
467left
>6
should raise
scapular
areasuspiscion of NF
>8 is highly predictive of NF

Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)
score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med
2004; 32:15351541.

Presenting signs and symptoms

Early

Advanced

Localized
Heat
Erythema
Edema
Pain
disproportionate
to injury

Malaise
Thirst
Diarrhea
Stomach pain
Vesicle
formation

Late
Confusion
Hypotension
Tachycardia
Shock

Sarah Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed. 2008.

 the only signs that were present in 50% of patients

were erythema, tenderness, or edema beyond what
appeared to be the confines of infection. This is in
contradistinction to standard teaching, which
stresses shock, fever, and mental status changes as
frequent findings.

Sarani B, Strong M, Pascual J, Schwab CW: Necrotizing fasciitis: current concepts

and review of the literature. J Am Coll Surg 2009, 208(2):279-88.

The most common area of involvement in the study was

the back .

A. Pandey, et.al: Surgical considerations in pediatric necrotizing fasciitis. J Indian Assoc Pediatr Surg>v.14(1);
Jan-Mar 2009
Legbo JN, Shehu BB. Necrotizing fasciitis: Experience with 32 children. Ann Trop Paediatr. 2005;25:1839.

Lab results:
Lab results:
CBC: Hgb:132
Hct: 39
WBC 11.7
Seg: .40
Lym:.50
Mon:.06
Eos: .03
Platetet ct: 467

PT: 11.3 sec

Control: 11.6
Activity: 100%
INR: 0.94
PTT: 37.4 sec
Control: 34.2

Laboratory Risk Indicator for NECrotizing fasciitis (LRINEC)

Parameter

Points

CRP

>150mg/L

Leukocytosis

15-25X103
>25X103

1
2

Hb (g/dL)

11-13
<11

1
2

Serum Na

<135 mmol/L

Serum glucose

>10 mmol/L

Creatinine

>141 umol/L

>6 should raise suspiscion of NF

>8 is highly predictive of NF
Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)
score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med
2004; 32:15351541.

A retrospective analysis was undertaken to assess

the applicability and usefulness of (LRINEC) score
between January 2002 and December 2005 with the
admission diagnosis of necrotising fasciitis
With a cut-off score of 6, the LRINEC score had a
sensitivity of 80%, specificity of 67%, a positive
predictive value of 57% and a negative predictive
value of 86% in distinguishing the patients with
proven necrotising fasciitis from those with severe
soft tissue infections.
M. J. Holland. Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score
to patients in a tropical tertiary referral centre. Anaesth Intensive Care 2009; 37: 588-592

 finger test - a 2 cm incision down to the deep fascia is

made under local anesthesia. Probing of the level of the
superficial fascia is then performed.
The lack of bleeding, foul smelling dishwater pus and
minimal tissue resistance to finger dissection constitute a
positive finger test, which is diagnostic of necrotizing
fasciitis.

Wong CH, Wang YS. The diagnosis of necrotizing fasciitis. Curr

Opin Infect Dis. 2005;18(2):101106.

Referred to Surgery
11th hour of HS
Debridement and excision
Findings:
necrotic tissue involving
the skin, subcutaneous
and muscle tissue

Wound discharge
Gram stain: no microorganism seen
CS: no growth after 24 hours
Blood CS:
no growth after 36 hours

Types of Necrotizing fasciitis

Necrotizing
fasciitis
type 1
(55-75%)

Mixed
anaerobes,
gram-negative
aerobic bacilli,
enterococci

Surgery, diabetes
mellitus,
peripheral vascular
disease

Destruction of fat and

fascia; skin may be
spared; involvement of
perineal area in
Fournier gangrene

Necrotizing
fasciitis
type 2

Group A
streptococcus

Penetrating
injuries, surgical
procedures,
varicella, burns,
minor cuts, trauma

Systemic toxicity,
severe local pain,
rapidly extending
necrosis of
subcutaneous tissues
and skin; gangrene,
shock, multiorgan
failure

MRSA

Adapted from Bisno & Stevens[192] with permission from Massachusetts Medical Society

Type 3- Vibrio vulnificus

Type 2 disease is the most common form of necrotizing

fasciitis in children.

Common Microbial Causes of Type I Necrotizing Soft-Tissue Infection

Organism

Gram stain

Percent of
isolates
(n=162)

Percent of
isolates
(n= 272)

Staphylococcus
aureus

Gram-positive
cocci

16

22

Streptococcus
species

Gram-positive
cocci

19

17

Klebsiella species

Gram-negative rod

10

Escherichia coli

Gram-negative rod

Gram-negative
bacteria
Anaerobic bacteria

18
7

18

Clostridia species (gram-positive rods) are a rare cause of necrotizing soft

tissue infection.
_

Sarani B, Strong M, Pascual J, Schwab CW: Necrotizing fasciitis: current concepts and
review of the literature. J Am Coll Surg 2009, 208(2):279-88.

Histopathologic result:
2nd Hospital stay
S/O:
Awake, comfortable
Afebrile
A> Necrotizing fasciitis
S/P debridement and
excision

Fragments of skin, subcutaneous

and fibromuscular tissue with
necrosis

P> daily wound care

continue anti-TBmeds
Add Ceftazidime 150mgKD q8
D/C Amikacin

4-12th Hospital stay

3 Hospital stay
rd

shift Ceftazidime
and Clindamycin to
Meropenem 120mgkD q8h
Vancomycin 40mgkD q6h

Afebrile
Playful
Good appetite
No purulent, foul-smelling
discharges on wound site
P> step down to
Ciprofloxacin 30mgkD q12 h
Clindamycin 20mgkD q6
for 1 week

 an empiric regimen using high-dose penicillin and

clindamycin is recommended to cover gram-positive and
anaerobic organisms.
In patients with polymicrobial infections, a -lactam/lactamase inhibitor combination, such as
ampicillin/sulbactam or piperacillin/tazobactam, should be
considered.

 Vancomycin, linezolid, daptomycin, or quinupristin/ dalfopristin

are recommended for empiric coverage of gram-positive
organisms because of concern for MRSA infection. The
incidence of clindamycin-resistant MRSA prohibits use of this
drug alone for coverage of gram-positive organisms in severe
infections.
Quinolones offer excellent soft-tissue penetration and can be
used to cover gram-negative organisms.
Duration of antibiotic at least a 10- to 14-day course.

Sarani B, Strong M, Pascual J, Schwab CW: Necrotizing fasciitis: current

concepts and review of the literature. J Am Coll Surg 2009, 208(2):279-88.

 In undefined cases, Gram-negative, Gram positive and

anaerobic bacteria must be addressed.
Mono-therapy includes imipenem-cilastatin, meropenem,
ertapenem, and piperacillin/tazobactam .
A combination-therapy adds vancomycin, linezolid or
daptomycin to a carbapenem or b-lactam/b-lactamase
inhibitor combination, if methicilin-resistant staphylococci
are possible.

Johannes Frank1, John H. Barker2, Ingo Marz. Necrotizing Fasciitis of the

Extremities. Eur J Trauma Emerg Surg 2008;34:22936

14th hospital stay (June 11, 2011)

discharged improved

Final Diagnosis:

Follow-up (15th day post-op)

Other treatment modalities

In severe group A streptococcal infections, the use of highdose intravenous polyspecific immunoglobulin (IGIV) has
been proposed as adjunctive therapy.
MOA: inhibition of the superantigen activity through
neutralizing antibodies, opsonization through M-specific
antibodies, and a general anti-inflammatory effect.

 Hyperbaric Oxygen Therapy (HBO)

Increase 02 saturation of infected wounds:
- bactericidal effect
- increase PMN function
- decrease Clostridial toxin production
- enhance wound healing