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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 286-289

Necrotizing fasciitis: An unusual causative pathogen


Department of Surgery, University of Dammam, Dammam, Kingdom of Saudi Arabia

Date of Web Publication27-Feb-2013

Correspondence Address:
Yasser AlJehani
Department of Surgery, University of Dammam, Dammam
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.107899

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  Abstract 

Necrotizing fasciitis (NF) is not uncommon but in the era of therapeutic and prophylactic antimicrobial, it is considered to be a rare entity. The diagnosis requires a prerequisite high index of suspicion. Many classifications of such a entity do exist depending mainly on the causative agent. Others have classified it according to the immune-competent status or the anatomical location. The causative agent varies depending on the patients' risk factors. We report a case of a 28-year-old female who developed NF in the postcesarean section period. She was managed by surgical debridement, and made a full recovery. The recovered pathogen was Providencia stuartii. The patient made a full and uneventful recovery. Such a report will increase the awareness of the existence of nontypical sole agents. This would initiate empirical therapy in timely fashion.

Keywords: Cesarean section, necrotizing fasciitis, Providencia stuaritii


How to cite this article:
AlJehani Y, Albuainain H, Zakaria H, Makhdom F, Al-Ansari R. Necrotizing fasciitis: An unusual causative pathogen. Int J Health Allied Sci 2012;1:286-9

How to cite this URL:
AlJehani Y, Albuainain H, Zakaria H, Makhdom F, Al-Ansari R. Necrotizing fasciitis: An unusual causative pathogen. Int J Health Allied Sci [serial online] 2012 [cited 2020 Apr 8];1:286-9. Available from: http://www.ijhas.in/text.asp?2012/1/4/286/107899


  Introduction Top


Fournier reported the entity of necrotizing fasciitis (NF) in 1889. [1] The term was coined in 1952 by Wilson. [2] Many types and classifications have been implicated reflecting the diversity of such entity. In general, it affects males more than females, and diabetes is the most common predisposing factor. According to regions, the genital and extremities were the most commonly affected. [3] Although rare, it carries a high mortality if not recognized early in the course of the disease. A high index of suspicion is required based on a variety of nonspecific physical signs that add to the diagnostic difficulties.


  Case Report Top


This is a report of a 28-year-old gravid 5 para 4 + 0 female, free of any chronic medical illnesses apart from having sickle cell trait. She underwent a cesarean section due to fetal distress. During the operation, she bled massively and the source of bleeding was controlled eventually. She was shifted to the intensive care unit (ICU) and resuscitated with several units of blood despite the difficulty encountered in obtaining compatible blood. She recovered and was discharged on the ninth day postoperatively. A day later, she started itching at the site of the incision and later developed a blister over the suprapubic area. Upon arrival to the hospital, a foul and copious greenish brown substance started to discharge from the lateral edges of the incision [Figure 1]. The patient was hemodynamically stable apart from having a low grade fever. Her local exam revealed a soft and lax abdomen with mild tenderness in the lower areas. A gray bulla measuring 12 × 10 cm was seen in the suprapubic area. The mentioned discharge continued through the Pfannenstiel's incision. Her lab investigations revealed leukocytosis. The patient had a computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous (IV) contrast and it showed an extensive amount of air subcutaneously with disruption of the fascia. No clear intraperitoneal pathology could be identified [Figure 2]. A provisional diagnosis of NF was made. She was started empirically on Tazobactam and Metronidazole. Intraoperatively, the bulla was excised and extensive surgical debridement was done [Figure 3]. The fascia was torn and necrotic. The wound was left open to heal by secondary intention and to facilitate possible further debridement sessions. The culture came to be positive for the monobactrium Providencia stuartii that was sensitive to the empirical antibiotics. Fortunately, she did not require any further debridement session and had a smooth postoperative course. The wound was closed after insuring no growth [Figure 4] and her follow-up after a month showed no further problems as well as the 1-year follow-up.
Figure 1: Abdominal wall showing the bulla measuring 10 × 8 cm

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Figure 2: Operative picture showing the amount of tissue destruction and necrosis

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Figure 3: Preoperative CT scan showing the subcutaneous air

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Figure 4: Three weeks after the treatment

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  Discussion Top


Necrotizing fasciitis is a rare entity. [3] It was documented initially by Fournier in 1883. [1] In 1920, Meleny identify 20 patients in China with the single organism; group A-hemolytic streptococci (GAS). Wilson coined the term NF in 1952. [2] It is a rapidly progressive soft tissue infection involving the superficial and deep fascia leading to thrombosis of cutaneous vessels and gangrene of the underlying tissue. [1] The lack of boundaries makes early diagnosis a challenge. The exact incidence is not known and 20% occurs as postoperative infections in some historical figures. The common sites of the body are the extremities 53%, perineum 20%, abdominal wall 18%, and head and neck 8.9%. [2],[4] Risk factors include any immunocompromised state, DM, cardiac disease, malnutrition, obesity, advanced age (>50 years), renal impairment, malignancy, trauma, burns, chronic alcoholism, hypoalbuminemia, IV drug abuse, occult diverticulitis, postoperative infections, associated strangulated hernias, steroid use, nonsteroidal anti-inflammatory drugs (NSAIDs) use, and peripheral vascular disease (PVD). Morbidity is highest in cases with DM, PVD, and age > 50 years. [2],[4],[5] NF is rare among obstetric cases but fulminant if occurs and mortality approaches 76%. [1],[2],[4] NSAIDs use has been implicated as a cause because of its impairment of the body's normal defense mechanisms effecting mainly granulocyte chemotaxis, phagocytosis, and bactericidal activities. [1],[6] GAS is recovered with no previous operations. Abrasions or even insect bites can act as a port of entry. Polymicrobial aerobic gram-positive (G +ve) and gram-negative (G -ve) and anaerobes were recovered from postoperative and post-trauma cases. The clinical presentation varies and is nonspecific. In the skin, erythema, pain that is disproportionate to the physical findings and extends beyond the visible margins, anesthesia or decreased sensation at the affected site, swelling, grayish purulent exudates, and bullae filled with maroon or violaceous fluid can be found. [1],[4] Crepitus is a late sign occurring in 18% of cases. Patients may show fever, diaphoresis, tachycardia, or delirium. Seventy-six percentage of cases correlate with pre-existing cellulites and 47% with bullae. [4] Regarding the causative agent, type 1 is a polymicrobial gram +ve and –ve organism and is commonly seen in vascularity compromised tissue, mainly in the extremities and in intra-abdominal fecal spillage. It is the commonest type and is responsible for 69% of cases. Type 2 is caused by GAS and mainly affects previously healthy individuals postoperative or post-trauma. Type 3 is caused by Clostridial spp. or Vibro spp. They cause 29% of the cases and carry mortality of 30% to 40%. Type 4, which is the least found, is caused by fungal infection, mainly Candida spp. and especially in immunecompromised patients. It is reported that no organisms were recovered in 2% of cases. [4] The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is capable of detecting even early cases especially if the score is more than six. It includes C-reactive protein, hemoglobin, white blood count, sodium, creatinine, and glucose levels. [7] In the case presented here, the causative pathogen was P. stuartii which is unusual. Providencia species causes various infections mainly urinary tract infections and travelers' diarrhea. [8] The incidence is increasing especially in certain risk groups. Rettger is the first to recognize the genus Providencia. It was isolated form chicken during a cholera epidemic and was named bacterium Rettger in 1918. The genus underwent many taxonomic changes and overlapped with the genera Proteus, Morganella, and Klebsiella. Kauffman first proposed the genus name Providencia in 1951 attributed to the work by Stuart in Providence, Rhode Island. [8] Nowadays, five species are recognized; Stuartii, Rettgeri, Alcalifaciens, Rustigianii, and Heimbachae. In humans, it is isolated from the throat, stool, urine, blood, perineum, axilla, wounds, and even from water sources. It is also isolated from poultry and reptiles. P. stuartii is responsible for most of the human infections and it usually inhabits long-term indwelling catheters. P. alcalifaciens, Rettgeri, and Stuartii cause travelers' diarrhea. Providencia accounts for 3% of all gram -ve infections. Sixty-one percentage of Providencia infections are caused by Stuartii, and it has also been reported to cause endocarditis. [9] Here, we report it as a cause of NF. Mortality ranges from 6% to 33%. The male-to-female ratio is equal. It is reported to be resistant to tetracycline, fluoroquinolone, and aminoglycosides and susceptible to late generation cephalosporins, aztreonam, and carbapenems. [4] The recommended treatment course is 7-14 days provided that the septic focus is targeted. The gold standard to diagnose NF is biopsy. [4] Subcutaneous air is present on plain radiographs in 25% of cases and its absence does not rule out NF. In addition, it does not correlate with a specific organism. [4] A CT scan can differentiate between cellulites and NF and is helpful in assessing the extent and depth of involvement. MRI T2 with gadolinium has high yield with hyperintense signals for fascia and a rim of enhancement for necrotic tissue. [2],[4],[5],[10] The treatment of NF is tailored according to the type, but it has to include aggressive resuscitation, empiric broad-spectrum antibiotics (Ampicillin, Gentamicin, Clindamycin, Flagyl, or antifungal). Extended spectrum antibiotics, such as Imipenium, are considered for suspected nosocomial gram -ve bacilli. For suspected fungal infections, some consider amphotericin B. [4] Surgical debridement is the cornerstone of treatment. Hyperbaric oxygen and immunoglobulin use is controversial. Due to the superantigenic reaction to the exotoxins, IV immunoglobulin use is claimed to neutralize the effect of damaged tissue that leads to multiorgan failure especially in streptococcal toxic shock syndromes. [5] After surgical debridement, a moist environment is essential to promote wound healing as well as to control copious exudates and malodors. Hydrofibers such as sodium methylcellulose are advised [1] and odor-absorbing dressings such as activated charcoal have been introduced. [11] From an infection control point of view, contacts are candidates for antimicrobial prophylaxis. These contacts are: those exposed for >4 h/day or 20 h/week, those sharing sleeping arrangement, and those within direct mucosal contact within 7 days. [5] Factors that affect patient survival are: prompt recognition, nutritional support, surgical debridement, wound re-exploration, and soft tissue coverage. [4]


  Conclusion Top


NF is a rare entity in the era of antimicrobial and improved infection control setup. A high index of suspicion is required in order to diagnose early in the course of the disease. Considering the rare causative agents helps in establishing empirical therapy, which is an essential part of the treatment in timely fashion.

 
  References Top

1.Haldar MK, Shabarwal SD, Moore PJ. Necrotizing fasciitis following a caesarean section. J Obstet Gynaecol 2004;24:87-8.  Back to cited text no. 1
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2.Gonzalez Castro A, Rodriguez-Borregan JC, Obeso T, Castellonos A, Perez-Ceballos A, Sensmero JR.Necrotizing fasciitis after caesarean section. Arch Gynecol Obstet 2008;277:579-81.  Back to cited text no. 2
    
3.Fazeli MS, Keramati MR. Necrotizing fasciitis: An epidemiological study of 102 cases. Indian J Surg 2007;69:136-9.  Back to cited text no. 3
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4.Headley AJ. Necrotizing soft tissue infections: A primary care review. Am Fam Physician 2003;68:232-8.  Back to cited text no. 4
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5.Cherneski CL, Embil JM. Necrotizing fasciitis. Saudi Med J 2001;22:565-8.  Back to cited text no. 5
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6.Van Ammers PM, Moore PJ, Sacho H. Necrotizing fasciitis after caesarean section associated with NSAID. A report of 3 cases. S Afr Med J 1991;80:203-4.  Back to cited text no. 6
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7.Wong CH, Khin LW, Heng KS, Tan KC, Low CO. 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;1535-41.  Back to cited text no. 7
    
8.O'Hora CM, Brenner FW, Miller JM. Classification, identification, and clinical significance of Proteus, Providencia and Morganella. Clin Microbiol Rev 2000;13:534-46.  Back to cited text no. 8
    
9.Krake PR, Tandon N. Infective endocarditis due to Providenciastuartii. South Med J 2004;97:1022-3.  Back to cited text no. 9
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10.Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulites using MR imaging. AJR Am J Roentgenol 1998;170:615-20.  Back to cited text no. 10
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11.Thomas S, Fisher B, Fram PJ, Waring MJ. Oudur-absorbing dressing. J Wound Care 1998;7:246-50.  Back to cited text no. 11
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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