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Necrotizing Fasciitis of the Abdominal Wall with Lethal Outcome:
A Case Report
Dubravko Huljev, M.D.
Specialist In General And Plastic Surgery
Department of Plastic and Reconstructive Surgery, Surgical Clinic
Sveti Duh General Hospital
Zagreb Crotia
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Citation:
Dubravko Huljev: Necrotizing Fasciitis of the Abdominal Wall with Lethal Outcome: A Case Report. The Internet Journal of Plastic Surgery. 2006. Volume 2 Number 2.
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Table of Contents
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Abstract
Necrotizing fasciitis is an acute surgical condition that demands a prompt and combined treatment. Early recognition, aggressive surgical debridement, and targeted antibiotic therapy significantly affect the overall course of treatment and, ultimately, survival. The authors present a case of a woman with necrotizing fasciitis of the abdominal wall and the course and methods of treatment. Because of comorbidy factors (extreme obesity, diabetes), and late proper diagnosis of necrotizing fasciitis (the clinical signs were "hidden" by celullitis, and phlegmona of abdominal wall), and then as the consequence, overdue adequate surgical treatment, unfortunately contributed to medical treatment failure, respectively lethal outcome.
Introduction
Progressive necrotizing inflammatory lesions of soft tissues are relatively rare entities in our everyday surgical practice. In USA there are approximately around 500 - 1500 cases per year.( 1 )
The term necrotizing fasciitis is used as the generic name for necrotizing infections of soft tissue. This term includes different syndromes of progressive necrotic infections of skin and subcutaneous tissue.( 2 ) It concerns rapid progressive infection, which affects the fascia and subcutaneous tissue, with simultaneous development of thromboses of skin microcirculation, resulting in necrosis of soft tissue and skin, destruction of muscles and liquefaction of fat( 2 , 3 )
Medical treatment is a very complex one. On the front burner is surgical debridement beside the aimed application of broad-spectrum antibiotics. Additionally, auxiliary measures can be applied, such as negative pressure wound therapy (NPWT) or hyperbaric oxygenation.( 4 , 5 ) Infection outcome is always uncertain, and the mortality in these patients is up to 80 %, depending upon associated comorbid factors, the way of treatment and the development of complications (the acute renal insufficiency, acute respiratory distress syndrome - ARDS and multiorganic failure - MOF).( 6 , 7 , 8 , 9 , 10 , 11 , 12 ) In this article has been presented the case of female patient with the necrotic fasciitis of bottom of abdominal wall, perineum and inquinofemoral region, who in spite of all the executed measures, resulted with the lethal outcome.
Case Report
Clinical status and course of treatment
A female patient 60 years old, obese (high 161 cm, weight 114 kg, BMI = 44), mother of five children, diabetic, had raised temperature, inflammatory changes in the area of groins and light pains in this area, which lasted in the past 3 days.
During the examination, a surgeon made the diagnosis of excessive body weight, hanging stomach, erythema and cellulites beside minimal sore spots of the bent and hanging bottom of abdomen. Furthermore, he recommended antibiotic therapy and directed the patient to the dermatologist. Two days after she was examined by the dermatologist who described the skin erythema of abdominal wall and groins, which were warm and milder painful sensitive.
Because of the general plight, the patient was hospitalized at the Internal Clinic, and the same day was moved to the Department of Nephrology, under the diagnosis of abdominal walls phlegmona. At the admittance the patient was conscious, febrile 38,4°C with the expressed erythema of wall of lower half abdomen and groins, with skin bullae filled with yellowish liquid contents. At the admittance sedimentation was 132, and leukocytes 8,23 x 109 / l. From urinoculture were isolated Escherichia coli and hemocultures were sterile. Daily doses of combined Tazocin 4 x 2,25 g and Diflucan a 100 mg were administered. Anemia was corrected with transfusions. During the hospitalization at the Internal Clinic, on a few occasions, the patient was examined by the surgeon when necrectomy and incisions were done. Microbiologically, Staphylococcus epidermidis was isolated from wound svab.
In spite of intensive antibiotic therapy, inflammatory and necrotic progression occurred and patient was moved to the Surgical Clinic until she died 3 months later.
At the time of admission to the Surgical Clinic, the patient was septic, in the state of borderline reversible septic shock, with marked high C-reactive protein (CRP), expressed heavy necrotic changes of soft tissue of right lower abdomen and perineal regions, complete destruction of labia majoris, and propagation of the process in perianal region and right gluteal region (Figures 1 and 2).
Figure 1: Excessive destructions of lower part of abdominal wall
Figure 2: Excessive destructions of lower part of abdominal wall (local view)
Immediately, urgent surgery and extensive necrectomy of bottom of abdominal wall and perineal region were accomplished (Figure 3).
Figure 3: Status of lower abdominal wall after extensive surgical debridement
Abundant decontaminations of wounds with the 3 % hydrogen peroxide and physiological solution were done. The defect was left opened. On places without the visible skin necrosis, incisions were done and drainage was introduced. Because of the general condition, the patient was placed in the Intensive Care Unit (ICU). During the operation, targeted samples were taken for microbiological examination. The combined therapy of daily doses of Tazocin 4 x 2,25 g with Diflucan a 100 mg was continued.
The following day, because of the doubt of streptococcal sepsis, the antibiotic therapy was changed, and in the agreement with the microbiologist, Clindamycin 3 x 900 mg, Penicilin G 4 x 5.000.000 U, and Mirocef 2x1g were introduced. Wound was daily writhing, beside the occasional necrectomy.
The seventh day after the surgery came to the more abundant bleeding from the wound area with the pressure loss, and deterioration of the general condition of the patient. The urgent wound revision was approached, and during the surgery the multiple bleedings in wound were found and the hemostasis was done. Postoperatively, patient remained on the respirator. Everyday wound writhing was continued, parallel with taking the material for micro- biological analysis, tracking laboratory parameters, especially the following ones: L (Figure 4), CRP (Figure 5), erythrocytes, potassium and sodium (Figure 6), urea and creatinine (Figure 7), central venous pressure (Figure 8) and diuresis (Figure 9). Antibiotic therapy was changed according to antibiograms findings, as agreed with the microbiologist (Figure 10). Patient is throughout the stay, the largest part febrile (Figure 11).
Figure 4: values of leukocytes during the treatment
Figure 5: Values of CRP during the treatment are in correlations with leukocytes values
Figure 6: Values of potassium and sodium
Figure 7: Values of urea and creatinin
Figure 8: Values of central venous pressure
Figure 9: Diuresis during the hospitalization
Figure 10: The administered antibiotics during the treatment
Figure 11: Body temperature
After twenty days of staying in ICU, because of the development of acute renal insufficiency, hemofiltration was accomplished beside patient's bed during 4 days, until to the establishment of diuresis, and depreciation of urea, creatinine and potassium. Because of the impossibility of detachment from the respirator and adequate toilet of respiratory tracts, the 37th day of hospitalization tracheostomy was performed.
After the obvious improvement, which appeared 6 weeks after the admittance, that included hemodynamic stability, the minimal support to the respiration, satisfactory diuresis and intestinal passage, as well as satisfactory local wound aspect, patient became continu- ously high feverish, that proved Candida sepsis, and became anuric, hemodynamically unstable with multiorganic suppression, which remained refracted on reanimation therapy, and lethal outcome occurred under the clinical signs of the irreversible septic shock.
Discussion
The first clear definition of necrotizing infections of soft tissues was given by Joseph Jones in 1871, as hospital gangrene( 13 ). The term necrotizing fasciitis was mentioned for the first time by Wilson in 1952 ( 14 ). Today's division is based upon tracking of more factors which in detail characterize the infection of soft tissue, determine the way of medical treatment and somehow predict the outcome. These predisposing factors include the period of incubation, etiologic causes, systemic toxicity, clinical course of infection, peculiarities of lesion and degree of tissue affection, respectively of gram stained tissues preparation, and the course of medical treatment ( 15 ). In this way we distinguish: necrotizing fasciitis, anaerobic streptococcal myositis, progressive bacterial synergistic gangrene, polymicrobical synergistic necrotizing cellulitis, nonclostridial or clostridial infections, and Fournier's gangrene ( 6 , 15 ).
Necrotizing fasciitis is the acute surgical condition. Early recognizing and surgical debridement of necrotic tissue are exceptionally important, and are significantly influencing upon the course of the treatment and patient's survival ( 16 , 17 , 18 , 19 ). In spite of the aimed and on time initiated therapies, the outcome of necrotizing fasciitis is always doubtful. Factors which determine the bad outcome of medical treatments are: the delayed incision or the one, 30 hrs. after the development of symptoms, the inadequate surgical treatment (insufficient debridement or the inadequate repetition of debridement), localization on the body, age higher than 65 yrs., male gender, present endogenous diseases, index of body weight higher than 40, infection caused with Streptococcus pyogenes (the serogroup A), transfusions, complications appearances, and immunosupression of any etiology ( 5 , 7 , 8 , 9 , 10 , 20 , 21 ). Inadequate surgical debridement and complication rate of expected mortality can be from 50 % ( 5 ) to 80 % ( 5 , 6 , 12 ).
During the initial examination, very frequently necrotic fasciitis is not recognized, even in 85% of cases ( 3 ), as the clinical signs are “hidden” with abscess or cellulitis (nonecrotic infection of soft tissues). Furthermore, in clinical signs only the light shape of cellulitis can dominate, while at the same time, necrotizing fasciitis can rapidly progress through the fascia and affects the muscle ( 19 ). In such patients the exact diagnoses can be obtained, only when the infection has rapidly progressed alongside the migration of edge of edemas, and skin induration in spite of intravenous application of antibiotics of wide spectrum.
The clinical signs are usually of acute course and develop in a couple of days. There are usually trials of the symptoms: pain, swelling and raised temperature. Sensitivity of skin, erythema, and locally the raised temperature of skin are frequently the only symptoms of an early phase of necrotizing fasciitis. Peculiarities of the developed clinical pictures are the system intoxication followed with fever, hemorrhagic skin bullas, celullitis in 90% cases, edema in 80%, necrosis skins, fluctuation, crepitations, sensory and motor deficit ( 6 ).
Pathophysiological process grips the skin, the subcutaneous tissue, fascia and muscles and has been characterized with angiothrombotic microbial invasion and liquefaction necrosis. Histologically the following is seen: necrosis of the superficial muscle fascia, infiltration of polymorfonuclears in deep dermis and fascia, thrombosis and suppuration veins and arteries which traverses fascia, and proliferations of microorganisms inside the destroyed tissue ( 5 , 22 ).
From microbiological point of view, it is a heavy polymicrobical infection caused by mixed aerobic and anaerobic microflora. Etiological causes are dominantly aerobic and anaerobic bacteria but can be system of fungi too. Dominant species are: Streptococcus spp, Staphylococcus spp, Peptostreptococcus spp, Peptococcus spp, Bacteroides spp, members families Enterobacteriacea and Pseudomonas aeruginosa ( 23 , 24 , 25 ). Except of the usual causes necrotizing fasciitis can caused by rare or bizarre originators, especially in the immunocompromise host. These are: Mycobacterium ulcerans, Stenotrophomonas maltophilia, Bacillus cereus, Vibrio vulnificus, and fungi as Curvularia brachyspora, Alternaria, Apophysomyces elegans subtip mucormycosis and also combinations of bacteria and fungi ( 6 , 15 , 26 , 27 , 28 , 29 , 30 , 31 ). Number of etiologic originators may be 1,2,3 and more ( 31 ).
Medical treatment of necrotizing fasciitis is complex and combined one. On the front burner is aggressive surgical debridement of the complete necrotic tissue, as well as the initial administration of broad spectrum antibiotics. Revision of wounds must be done inside 24 - 48 hrs because of the evaluation for the additional debridement. In therapeutic procedures, time is highly important factor for the prognosis and outcome of medical treatments. The optimal time interval for the first debridement is inside 6 hrs according to the appearance of clinical symptoms. Moreover, supporting procedures such as hyperbaric oxygenation and NPWT can be applied too ( 4 , 32 , 39 , 40 ).
Before the development of clinical signs of necrotizing infections of soft tissues, probably sore spots in the area of bottom of abdomen have preceded. Predisposing factors to the development infections are: diabetes mellitus, age, and body index mass higher than 40. The development of infections was gradual with the development of celulitis, edemas and fever, the same was with the development of intoxication with the resultant development of sepses. Etiologic originators were aerobic and anaerobic bacteria Enterococcus faecalis, Escherichia coli, Acinetobacter baumannii, Candida spp., and Proteus mirabilis. In the further course from microbiological specimens MRSA and Pseudomonas aeruginosa were isolated. In spite of the intensive combined medical treatment through the period the 60 days, it came to further progression and deterioration of patient's condition, then sepsis caused by Candida, MOF, renal insufficiency, anergies, respectively failing of vital functions and lethal outcome.
Conclusion
In the presented case, there have been a few failures in the course of medical treatments. The first diagnoses were celullitis and abdominal wall phlegmona. During the first examination surgeon, and later on dermatologist, respectively internists did not take in the consideration the differential diagnostic entity of necrotizing fasciitis. Initially, no incisions were done, and in the later phase when bullosis of skin developed the inadequate incisions and drainages were done. The adequate surgical treatment - the extensive necroctomy (when patient was admitted to Surgical Clinic) was done too late, still 2 weeks after the beginning of clinical signs development. At that moment, the patient was already significantly septic and in serious physical condition. Unfortunately, because of the impossibility, the auxiliary measures such as NPWT or hyperbaric chamber were not applied.
Because of comorbidity factors (extreme obesity, diabetes), and late proper diagnosis
of necrotizing fasciitis (the clinical signs were “hidden” by celullitis, and phlegmona of abdominal wall), and then as the consequence, overdue adequate surgical treatment, unfortunately contributed to medical treatment failure, respectively lethal outcome. This of course don't means that the patient would survived, since the mortality under such circumstances brings out and to 80 %, but without this “failures” chances for surviving would be greater.
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