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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 25  |  Issue : 2  |  Page : 144-147

Neonatal necrotizing fasciitis: Two case reports and literature review


1 Department of Paediatrics,University of Nigeria, Enugu Campus; Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
2 Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
3 Plastic Surgery Unit, Department of Surgery, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria

Date of Submission14-Jan-2020
Date of Decision21-Feb-2020
Date of Acceptance13-Jun-2020
Date of Web Publication29-Jul-2020

Correspondence Address:
Uzoamaka C Akubuilo
Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_5_20

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  Abstract 

Necrotizing fasciitis is a severe infection of the deep soft tissues, which results in a progressive necrosis of the muscle fascia and overlying subcutaneous fat. It occurs less frequently in children, where it’s most likely associated with depressed or suboptimal immunity. Prompt diagnosis and aggressive multidisciplinary management will reduce morbidity and mortality. We present two cases of neonatal necrotizing fasciitis managed in our facility to create awareness of such rare cases in our environment.

Keywords: Children, necrotizing fasciitis, neonates


How to cite this article:
Obu HA, Obumneme-Anyim I, Iloh KK, Akubuilo UC, Okwesili OR, Achebe UJ. Neonatal necrotizing fasciitis: Two case reports and literature review. Int J Med Health Dev 2020;25:144-7

How to cite this URL:
Obu HA, Obumneme-Anyim I, Iloh KK, Akubuilo UC, Okwesili OR, Achebe UJ. Neonatal necrotizing fasciitis: Two case reports and literature review. Int J Med Health Dev [serial online] 2020 [cited 2020 Aug 15];25:144-7. Available from: http://www.ijmhdev.com/text.asp?2020/25/2/144/291065




  Introduction Top


Necrotizing fasciitis (NF) is a severe, rare, and rapidly progressive life-threatening infection of the fascia with secondary necrosis of the subcutaneous tissues.[1] Organisms spread from the subcutaneous tissue along the superficial and deep fascial planes with the deep infection causing vascular occlusion, ischemia, and necrosis.[2] In the past, it had been described by several terms such as hemolytic streptococcal gangrene, Meleney’s ulcer, hospital gangrene, suppurative fasciitis, and synergistic necrotizing fasciitis,[2] until Wilson,[3] in 1952, introduced the term “necrotizing fasciitis.”[3] NF is uncommon in children and immunocompetent individuals in the developed countries of the world, where it is described among adults with immunosuppressive disorders such as diabetes mellitus. However, in developing countries, reports in children exist. Incidence of 0.3–15 per 100,000 has been reported around Europe and America,[5] and in Nigeria, approximately 10–16 cases per year have been reported in recent reviews with a child:adult ratio of 1.7:1.[4],[6] It is often polymicrobial, and the synergistic action of the organisms may contribute to the fulminant course.[4] NF is a potentially fatal condition with death rate ranging from 12% to 50%.[4],[5],[6],[7]

We report two cases of necrotizing fasciitis in our facility to create awareness and to educate the reader on the occurrence and nature of this disease. These will be compared with and strengthen the few available reports from other regions of the country.


  Case Series Top


Case 1

Baby AE was a 3-week-old female who presented with ulcers over the chest and abdomen. The lesions were said to have started as a boil over the left breast with subsequent ulceration, following some maneuvers on the fifth day of onset with progressive increase in size. Baby also had fever, refusal of feeds, and jaundice. Home care included oral penicillin with periodic massage of the boil in an attempt to expel pus. Parents were of low socioeconomic class, and the child was on predominant breastfeeding before the onset of illness. Salient examination findings were poor activity, pallor, fever, moderate dehydration with an irregularly circumscribed ulcer extending from the nipple line to the epigastrium measuring approximately 10cm × 16cm with a surrounding area of erythema, necrotic tissues, and sloughs [Figure 1]. Wound swab microscopy, culture, and sensitivity yielded Staphylococcus aureus sensitive only to amikacin. Full blood count showed leukocytosis (25 × 109/L) with neutrophilia (74%) and hemoglobin level of 7.4 g/dL. Retroviral screening was negative, and renal function was optimal.
Figure 1: Patient 1 at admission and discharge

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Empirical antibiotics regimen of intravenous ceftriaxone, clindamycin, gentamicin, and metronidazole was started before obtaining culture result. This was subsequently reviewed after 72h with sensitivity result. Amikacin was substituted for gentamicin in the antibiotic regimen and was given for 7 days. She was transfused twice, and had serial debridement and daily occlusive wound dressing using normal saline and honey. Daily wound dressing was done for 4 weeks, followed by alternate daily dressing for another 2 weeks. Baby had conjugated hyperbilirubinemia, which resolved gradually with the treatment of the sepsis. She achieved good wound healing by secondary intention, and was discharged to the clinic where she was seen once, and was subsequently lost to follow-up.

Case 2

Baby MN was a male neonate admitted on the 19th day of life. He had developed diffused swelling and redness of the left arm, which started as a boil over the left arm and subsequently was ulcerated by the 4th day, and it subsequently involved the left side of the chest wall, extending laterally to the back. He subsequently developed fever and difficulty with breathing necessitating presentation to the hospital. He was predominantly breastfed, and parents were also of low socioeconomic class. On admission, he was in respiratory distress with diffused tenderness and erythema over the left side of the chest, axilla, and back [Figure 2]. The erythema extended from the infraclavicular area to the level of the umbilicus. There was a necrotic/gray area on the left side below the axilla, slightly extending to the back and measuring about 8cm × 6cm. He was empirically started on intravenous clindamycin, metronidazole, and ceftazidime. Full blood count showed leukopenia (white blood cell, 3.6 × 109/L, neutrophil, 47%, and lymphocyte, 52%). Wound swab microscopy, culture, and sensitivity yielded heavy growth of Proteus species sensitive only to imipenem and resistant to ceftazidime and metronidazole, necessitating a change of antibiotic therapy to imipenem, and the earlier antibiotics were discontinued. Extensive wound debridement was done on admission, followed by daily wound dressing using normal saline and honey. Imipenem was given for 10 days; wound healing progressed satisfactorily by secondary intention, and the patient was discharged from hospital after 5 weeks; however, alternative day outpatient treatment was continued for 3 weeks.
Figure 2: Patient 2 at admission and discharge on day 34

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  Discussion Top


The young age of the patients supports the knowledge that necrotizing fasciitis is associated with suboptimal immunity. Previous studies in Nigeria have also documented the condition in children less than 1 year.[4],[6] Children less than 1 year of age constituted 25% of the cases in a 4-year series of necrotizing fasciitis in Sokoto.[4] Similarly, 10% of cases in a series in Ilorin were in children less than 1 year.[6] In developed countries, necrotizing fasciitis is rare in children and neonates.[2] This strongly suggests that in younger children and neonates, the disease may be related to poor hygienic practices as well as poor health-seeking behavior as shown in our two cases where both patients were of low socioeconomic status. Poor hygienic and improper infant feeding practices were also seen in both cases. It can occur in both males and females as seen in our reports. However, previous Nigerian studies in children have suggested a male predominance.[4],[6],[8] This male predominance possibly follows the assertion that neonatal sepsis is more common in males than females in all races.[9],[10] The very small number of cases in our report, however, did not allow observation and conclusion of gender involvement in NF in our environment.

The index cases had lesions involving the chest. Reports have shown that many cases in childhood in developing countries are preceded by boils around the breast,[11] such as seen in our patient, omphalitis,[12] appendicitis, and intra-abdominal abscess.[8] The upper half of the body has been reported as the most common site in children;[8],[13],[14],[15] unlike the adults where the lower half is the most frequently involved. This inadvertently is in keeping with the fact that the common precipitating lesions in children are in the upper parts of the body such as the chest and umbilicus.[8],[11],[12] Group A beta hemolytic streptococcus has historically been described as the most common cause of the condition.[2] Others include S. aureus and gram-negative organisms. The organisms, such as S. aureus and Proteus species, isolated in our patients follow documented trends, and they have also been isolated in children in other parts of the country.[4],[6],[8] NF can be polymicrobial (type 1) or monomicrobial (type 2). Owing to the paucity of anaerobic cultures in many centers in our environment, it therefore may be difficult to isolate all offending organisms and properly classify the disease.

Hallmark symptoms of pain, erythema, fever, malaise, and other features of sepsis[2] were seen in the index cases. Typically, the infection begins with an area of erythema that quickly spreads over a course of hours to days as typified in the index cases.[2] The redness quickly spreads into surrounding normal skin; and with progress, the skin near the site of insult develops a dusky or purplish discoloration. These stages were clearly observed in our second case. Usually some degree of intravascular volume loss is detectable on clinical examination, along with other general signs such as fever.[2] Our first patient presented with moderate dehydration and other systemic features such as refusal of feeds. Early diagnosis, aggressive surgical intervention (serial debridement), combined with supportive therapy, are crucial to the successful treatment of the disease.[2],[6] The index cases benefited from serial debridement, adequate supportive care, which included appropriate fluid and nutritional management, and rational use of antibiotics. The serial debridement aimed to impede the ongoing tissue destruction. The use of honey as the primary wound dressing agent in our cases contributed to the satisfactory wound healing process achieved. This has also been documented in other reports of NF.[4],[8] Honey has antibacterial, anti-inflammatory, and antioxidant properties.[16],[17] As an antibacterial agent, it is reported to be effective against aerobes and anaerobes, gram positives, and gram negatives.[18] In addition to the antimicrobial effect, honey maintains a moist wound environment that promotes healing, and has a high viscosity, which helps to provide a protective barrier against infection.[19] Other properties include deodorization of offensive wounds and promotion of granulation tissue formation and epithelialization,[4] and its hygroscopic property, which enables it to dehydrate bacteria, rendering them inactive. Early diagnosis is important to improve outcome. However, the disease is often misdiagnosed as cellulitis or mastitis, often leading to delay in presentation. Both of our patients had received care at home with oral antibiotics and in a primary health center for about 1 week before referral. This delay affects outcome inadvertently. Although we recorded no mortality in our patients, the mortality rate in NF ranges from 12% to 50%.[4],[6]

In conclusion, NF is an aggressive, life-threatening infection, which can affect neonates, and it requires early diagnosis, prompt resuscitation, serial debridement, and appropriate antibiotic therapy in a multidisciplinary management approach, including pediatricians and plastic surgeons.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A Current concepts in the management of necrotizing fasciitis. Front Surg 2014;1:36.  Back to cited text no. 1
    
2.
Schulz S Necrotizing fasciitis. Medscape. Available from: emedicine.medscape.com/article/2051157. [Last accessed 2020 May 20].  Back to cited text no. 2
    
3.
Wilson B Necrotising fasciitis. Am J Surg 1952;18:416-31.  Back to cited text no. 3
    
4.
Legbo JN, Shehu BB Necrotizing fasciitis: A comparative analysis of 56 cases. J Natl Med Assoc 2005;97:1692-7.  Back to cited text no. 4
    
5.
Stevens DL, Bryant AE Necrotizing soft-tissue infections. N Engl J Med 2017;377:2253-65.  Back to cited text no. 5
    
6.
Adigun I, Abdulrahaman L Necrotizing fasciitis in a plastic surgery unit: A report of ten patients from Ilorin. Niger J Surg Res2004;6:21-4.  Back to cited text no. 6
    
7.
Ravi R, Naresh R Review on necrotizing fasciitis: A rare flesh eating disease. Microbiol Int J 2017;2:113.  Back to cited text no. 7
    
8.
Awe O, Kesieme E, Kayode-Adedeji B, Aigbonoga Q Necrotizing fasciitis of the chest in a neonate in Southern Nigeria. Case Rep Paediatr2014;2014:818059.  Back to cited text no. 8
    
9.
Gollehon N Neonatal sepsis. emedicine. Available from: emedicine.medscape.com/article/978352. [Last accessed on 2020 May 24].  Back to cited text no. 9
    
10.
Simonsen KA, Anderson-Berry AL, Delair SF, Davies HD Early-onset neonatal sepsis. Clin Microbiol Rev 2014;27:21-47.  Back to cited text no. 10
    
11.
Bodemer C, Panhans A, Chretiens-Marquet B, Cloup M, Pellerin D, De Prost Y Neonatal necrotizing fasciitis: A report of three cases and review of the literature. Pediatrics 1997;131:466-9.  Back to cited text no. 11
    
12.
Ameh EA, Nmadu PT Major complications of omphalitis in neonates and infants. Pediatr Surg Int 2002;18:413-6.  Back to cited text no. 12
    
13.
Coleman DJ, Humzah M Plastic and reconstructive surgery, skin lesions. In: Williams NS, Bulstrode CJK, O’Connell PR, editors. Bailey & Love’s short practice of surgery. 25th ed. Edward Arnold (publishers) ltd, London; 2008. pp. 394-409.  Back to cited text no. 13
    
14.
Sachdev A, Seth S Necrotizing fasciitis. Indian J Pediatr 2004;41:623.  Back to cited text no. 14
    
15.
Khan AT, Tahmeedullah Obaidullah. Treatment of necrotizing fasciitis with quinolones. J Coll Physicians Surg Pak 2003;13:649-52.  Back to cited text no. 15
    
16.
Yaghoobi R, Kazerouni A, Kazerouni O Evidence for clinical use of honey in wound healing as an anti-bacterial, anti-inflammatory anti-oxidant and anti-viral agent: A review. Jundishapur J Nat Pharm Prod 2013;8:100-4.  Back to cited text no. 16
    
17.
Manisha D, Shyamapada M Honey: Its medicinal property and antibacterial activity. Asian Pac J Trop Biomed 2011;1:154-60.  Back to cited text no. 17
    
18.
Molan PC The antibacterial nature of honey. The nature of the antibacterial activity. Bee World 1992;73:5-28.  Back to cited text no. 18
    
19.
Lusby PE, Coombes AL, Wilkinson JM Bactericidal activity of different honey against pathogenic bacteria. Arch Med Res 2005;36:464-7.  Back to cited text no. 19
    


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