Necrotising fasciitis is commonly present in adults with comorbidities, but the difference with children is that it can occur in previously healthy kids, with a history of trauma to the skin. Acute cases show a progression of signs and symptoms in days (10), and all of our patients were considered acute cases. Early recognition, antibiotic impregnation and emergency surgical exploration and debridement are essential to avoid life threatening complications (11). Some authors suggest as a first line antibiotic, the use of high-dose penicillin G or cephalosporin, plus clindamycin or metronidazole, with or without an aminoglycoside (12,13).
Necrotising fasciitis can be seen everywhere in the body but it is more common in the abdominal wall, extremities and Perineum (14). Periorbital involvement is rare (15), and Luksich et al. recommends a conservative approach if the infection shows no sign of extension into the orbit (16). Some authors recommend that all patients without signs of sepsis can be safely managed with medical treatment to allow the necrotic areas to auto-demarcate, and then, the necrotic tissue should be debridement as needed (17).
The diagnosis of necrotising fasciitis is clinical. Magnetic Resonance Imaging is useful to differentiate between necrotic soft tissue infection and edematous tissue (18), but treatment should not be delayed just to obtain a study.
In a 13 months surveillance study throughout the UK and Ireland, 12 of 112 children had varicella complicated with a soft tissue infection, being necrotising fasciitis present in 7. Of the cultures taken, they could only confirm a specified microbiological agent in 6 patients, being the most frequent a Group A Streptococcus (19). In our study, only 3 patients had positive cultures, being the most common isolated bacteria, a Group A Streptococcus.
There are 3 risk factors that predict mortality in patients with necrotising fasciitis: advanced age, immunocompromise, and streptococcal toxic shock syndrome (20). None of our patients had those risk factors, and everyone had a prompt surgical and medical treatment, and we didn’t have any lethal complication.
Some authors have suggested a possible association between the use of non-steroidal anti-inflammatory drugs and an increased risk of varicella-associated necrotizing fasciitis, although this association remains controversial (21). In Mexico the use of paracetamol and methamizol in children is frequent and it was present in the medical history of all of our cases, but we cannot certainly affirm the association of its use and the presence of necrotising fasciitis.
It is essential to make an early diagnose of necrotising fasciitis and begin with a prompt treatment with IV antibiotics, IV fluids, and surgical debridement. Sometimes, many debridements are going to necessary, especially if done early, as necrosis may progress. Some patients presenting with septic shock should be aggressively treated to avoid lethal complications. If the patient is stable and non septic, the first debridement can be delay to allow necrotic tissue to demarcate. Reconstruction techniques are plenty and vary depending on the affected area, diameter, and clinical status. Every reconstruction technique must be individualized in each patient.
Conflict of interest: None.
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