gms | German Medical Science

Background: Necrotising fasciitis is a severe, life-threatening infectious condition. Bacterial invasion of the subcutaneous tissues with subsequent release of endotoxins and exotoxins causes tissue ischemia and liquefactive necrosis. Subsequent systemic inflammation is common, morbidity and mortality are high.

Until now, approximately 140 paediatric cases have been reported in the literature. The outcome of published cases is heterologous. To demonstrate a positive outcome with restitution ad integrum, we report the following case.

Materials and methods: A previously healthy 12-months old boy was referred to our emergency department with fever for two days. He had been vaccinated for mumps, rubella and meningococci four days previously in the left deltoid muscle.

Clinical examination upon arrival revealed a reduced general health; high temperature: 39.9°C; tachycardia 207/min; normal blood pressure 111/75 (85); normal oxygen saturation of 98%; tachy- and dyspnoea, rhinitis and a mild exanthema on the torso. The child was transferred to a paediatric ward under the running diagnoses of upper airway infection and treated with NSAR. Revaluation after eight hours showed the general state deteriorated; additionally a painful swelling on the left chest was seen. Laboratory findings are summarized in table one.

Necrotising fasciitis was considered. Clinical inspection ruled out benign skin irritations or phlegmon: the process was extremely painful, heated and a hard mass of about 10x10x1cm could be palpated. The LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) summed up to 11. Table 1 [Tab. 1]

Intravenous antibiotics (amoxicillin with clavulanic acid and clindamycin) were started. Three hours after initial consideration of necrotising fasciitis, an incision of 15cm on the lateral chest wall was carried out. Inspection showed intense subcutaneous swelling, enlarged lymph nodes and the presence of a milky-murky fluid. Lymph node and microbiological samples were collected and vacuum therapy was applied. Wound cultures grew out Streptococcus pyogenes in all samples and in high numbers. Histology revealed necrosis of the sampled lymph nodes.

The general state of the patient improved after surgery. Vacuum therapy was continued for 13 days. Small areas of necrotic tissue were resected on second look surgery until no necrotic tissue could be found anymore. The wound was closed on day 13 with a single drain, which could be removed after 4 days. The wound healed uneventfully.

Results: Restitutio ad integrum could be achieed after early diagnosis and aggressive therapy.

Conclusion: Theoretical knowledge, clinical experience and early consideration of this rare entity turned out to be crucial to enable early and aggressive antibacterial and surgical therapy. This proofed highly successful in the case presented.

Vaccination as a triggering factor for necrotising fasciitis has not been reported in the literature previously. Regular publication of occurrences is essential to further understand this rare infectious condition.