Necrotising fasciitis as a complication of varicella in children
Autor: Dr. Santino Figueroa Ángel | Publicado:  25/09/2012 | | |
Necrotising fasciitis as a complication of varicella in children .3

DISCUSSION:

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.


CONCLUSIONS

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.

ACKNOWLEDGEMENT: NONE
Conflict of interest: None.
Funding: None.

REFERENCES

(1). Gnann JW Jr. Varicella-zoster virus: atypical presentations and unusual complications. J Infect Dis. 2002 Oct 15;186 Suppl 1:S91-8.
(2). Snel BJ, Visconti G, Grabietz PD, Werker PM. Necrosis of nose skin after varicella zoster infection: a case report. J Plast Reconstr Aesthet Surg. 2010 May;63(5):e445-7.
(3) Peterson CL, Mascola L, Chao SM, et al. Children hospitalized for varicella: a pre-vaccine review. J Pediatr 1996; 129:529-36
(4). Dryden MS. Skin and soft tissue infection: microbiology and epidemiology. Int J Antimicrob Agents. 2009 Jul; 34 Suppl 1:S2-7.
(5). Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest 1996; 110: 219–29.
(6). El-Khani U et al. Multifocal necrotising fasciitis: An overlooked entity?. J Plast Reconstr Aesthet Surg. 2011 Sep 24.
(7). Chapnick EK, Abter EI. Necrotizing soft-tissue infection. Inf Dis Clin N Am 1996; 10: 835–55.
(8). Shirley R, Mackey S, Meagher P. Necrotising fasciitis: a sequelae of varicella zoster infection. J Plast Reconstr Aesthet Surg. 2011 Jan;64(1):123-7. Epub 2010 Jun 8.
(9). Moss RL, Musemeche CA, Kosloske AM. Necrotizing fasciitis in children: prompt recognition and aggressive therapy improve survival. J Pediatr Surg. 1996 Aug;31(8):1142-6.
(10). Whallett EJ, Stevenson JH, Wilmshurst AD. Necrotising fasciitis of the extremity. J Plast Reconstr Aesthet Surg. 2010 May;63(5):e469-73. Epub 200
(11). McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995; 221: 558–63.
(12). Vinh DC, Embil JM. Rapidly progressive soft tissue infections. Lancet Infect Dis. 2005 Aug;5(8):501-13.
(13). Moss RL, Musemeche CA, Kosloske AM. Necrotizing fasciitis in children: prompt recognition and aggressive therapy improve survival. J Pediatr Surg. 1996 Aug;31(8):1142-6.
(14). El-Khani U et al. Multifocal necrotising fasciitis: An overlooked entity?. J Plast Reconstr Aesthet Surg. 2011 Sep 24.
(15). Snel BJ, Visconti G, Grabietz PD, Werker PM. Necrosis of nose skin after varicella zoster infection: a case report. J Plast Reconstr Aesthet Surg. 2010 May;63(5):e445-7.
(16). Luksich JA, Holds JB, Hartstein ME. Conservative management of necrotizing fasciitis of the eyelids. Ophthalmology 2002; 109:2118e22.
(17). Fung V, Rajapakse Y, Longhi P. Periorbital necrotising fasciitis following cutaneous herpes zoster. J Plast Reconstr Aesthet Surg. 2012 Jan;65(1):106-9. Epub 2011 Jul 23.
(18). El-Khani U et al. Multifocal necrotising fasciitis: An overlooked entity?. J Plast Reconstr Aesthet Surg. 2011 Sep 24.
(19). Cameron JC, Allan G, Johnston F, Finn A, Heath PT, Booy R. Severe complications of chickenpox in hospitalised children in the UK and Ireland. Arch Dis Child. 2007 Dec;92(12):1062-6. Epub 2007 Nov 8.
(20). Golger A, Ching S, Goldsmith CH, Pennie RA, Bain JR. Mortality in patients with necrotizing fasciitis. Plast Reconstr Surg. 2007 May;119(6):1803-7.
(21). Zerr DM, Alexander ER, Duchin JS, Koutsky LA, Rubens CE. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics 1999;103:7



Categorías
Buscar publicaciones:



 Búsqueda Avanzada




  Revista Electrónica de PortalesMedicos.com

Revista de Medicina y Ciencias de la Salud, de periodicidad quincenal, dirigida a los profesionales de la Salud de habla hispana. ISSN 1886-8924