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Necrotizing Fasciitis
Report of 39 Pediatric Cases
Antonio Fustes-Morales, MD;
Pedro Gutierrez-Castrellon, MD;
Carola Duran-Mckinster, MD;
Luz Orozco-Covarrubias, MD;
Lourdes Tamayo-Sanchez, MD;
Ramon Ruiz-Maldonado, MD
Arch Dermatol. 2002;138:893-899.
ABSTRACT
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Background Necrotizing fasciitis (NF) is a severe, life-threatening soft tissue
infection. General features and risk factors for fatal outcome in children
are not well known.
Objective To characterize the features of NF in children and the risk factors
for fatal outcome.
Design Retrospective, comparative, observational, and longitudinal trial.
Setting Dermatology department of a tertiary care pediatric hospital.
Patients All patients with clinical and/or histopathological diagnosis of NF
seen from January 1, 1971, through December 31, 2000.
Main Outcome Variables Incidence, age, sex, number and location of lesions, preexisting conditions,
initiating factors, clinical and laboratory features, diagnosis at admission,
treatment, evolution, sequelae, and risk factors for fatal outcome.
Results We examined 39 patients with NF (0.018% of all hospitalized patients).
Twenty-one patients (54%) were boys. Mean age was 4.4 years. Single lesions
were seen in 30 (77%) of patients, with 21(54%) in extremities. The most frequent
preexisting condition was malnutrition in 14 patients (36%). The most frequent
initiating factor was varicella in 13 patients (33%). Diagnosis of NF at admission
was made in 11 patients (28%). Bacterial isolations in 24 patients (62%) were
polymicrobial in 17 (71%). Pseudomonas aeruginosa
was the most frequently isolated bacteria; gram-negative isolates, the most
frequently associated bacteria. Complications were present in 33 patients
(85%), mortality in 7 (18%), and sequelae in 29 (91%) of 32 surviving patients.
The significant risk factor related to a fatal outcome was immunosuppression.
Conclusions Necrotizing fasciitis in children is frequently misdiagnosed, and several
features differ from those of NF in adults. Immunosuppression was the main
factor related to death. Early surgical debridement and antibiotics were the
most important therapeutic measures.
INTRODUCTION
NECROTIZING fasciitis (NF) is a rare, rapidly progressive, and potentially
fatal infection of the superficial fascia and subcutaneous cellular tissue.1-2 Necrotizing fasciitis is frequently
polymicrobial, and the combination of aerobic and anaerobic bacteria contributes
to the quick progression and severity of the disorder.3
Necrotizing fasciitis has been known since antiquity.4-5
In 1871, Jones6 gave the first clinical description
of "hospital gangrene." In 1924, Meleney7 wrote
a classic report on NF, emphasizing the importance of early diagnosis and
surgical treatment to reduce mortality. In 1952, Wilson8
proposed the term necrotizing fasciitis to replace
terms like gangrenous erysipelas, hospital gangrene, acute
cutaneous gangrene, nonclostridial crepitant cellulitis, streptococcal gangrene,
synergistic necrotizing cellulitis, Meleney cellulitis, and others.
In addition, Wilson8 differentiated NF from
disorders like erysipelas, cellulitis, and clostridial myonecrosis with muscle
involvement. At present, a popular synonym is flesh-eating
bacteria disease9.
Series of NF in children are scarce and include few cases,1, 10-14
with less than 100 in the literature.1-2,10-24
The present series of 39 cases is, to our knowledge, the largest reported.
PATIENTS AND METHODS
STUDY DESIGN
We performed a retrospective, observational, comparative, and longitudinal
study.
SAMPLE POPULATION
We included all clinical records of patients hospitalized in the National
Institute of Pediatrics, Mexico City, Mexico, with a diagnosis of NF from
January 1, 1971, through December 31, 2000. We included all patients aged
1 day to 18 years of either sex with a diagnosis of NF.
STATISTICAL CONSIDERATIONS
The sample size needed to be considered significant was calculated as
35 to 40 patients. We used a commercial statistical software package (SPSS
Base System; SPSS Inc, Chicago, Ill) for data analysis. All studied variables
were analyzed in univariate form using t or  2 test (P .05 was considered significant).
Significant factors in the univariate analysis to predict risk for death were
included in a logistic regression multivariate analysis.
RESULTS
We found 39 patients with a diagnosis of NF during the 30-year study
period, representing 0.018% of all hospitalized patients. Of these, 21 (54%)
were boys, and 18 (46%) were girls. Ages ranged from 10 days to 15.5 years
(mean ± SD age, 4.4 years ± 4.7 months). The number and location
of lesions, preexisting conditions, initiating factors, bacterial isolations,
complications, evolution, and sequelae are shown in Table 1.
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Features in 39 Patients With Necrotizing Fasciitis*
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The signs and symptoms at the time of diagnosis were fever in 36 patients
(92%), vomiting in 21 (54%), hypotension and irritability in 13 (33%) each,
prostration in 11 (28%), hyporexia in 8 (21%), altered consciousness in 6
(15%), impaired peripheral perfusion in 5 (13%), hypothermia in 2 (5%), and
hypertension in 1 (3%). Local signs and symptoms were pain, hard edema, and
erythema in all patients; local warmth in 33 (85%); and functional limitation
in 29 (74%). Ecchymoses and necrosis were each recorded in 28 patients (72%),
hemorrhagic blisters in 25 (64%), purulent secretion in 16 (41%), serous blisters
in 14 (36%), local delayed capillary refill in 7 (18%), and crepitus in 4
(10%).
Serum laboratory findings showed hemoglobin levels ranging from 4.0
to 14.8 g/dL (mean level, 9.5 g/dL); hematocrit levels, 12% to 48% (mean level,
29%); white blood cell count, 300 to 72 000 cells/µL (mean, 16 552
cells/µL); neutrophil levels, 18% to 87% (mean level, 59%); lymphocyte
levels, 8% to 70% (mean level, 32%); monocyte and eosinophil levels, within
the reference ranges; bands, 0% to 33% (mean, 4%); and platelet count, 10
to 400 x103/µL (mean, 188.4 x103/µL).
Results of radiographic studies performed in 13 patients (33%) showed
soft tissue swelling in all and gas in 3 (8%).
Diagnoses at admission were cellulitis in 23 patients (59%), NF in 11
(28%), and gangrene in 5 (13%). Concomitant diagnoses were recorded in 17
patients (44%), ie, septicemia in 10 (59%) of these and humeral osteomyelitis,
febrile neutropenia, hemorrhagic varicella, septic arthritis, malnutrition,
acute diarrhea, and disseminated intravascular coagulation in 1 patient each
of the remaining 7.
Initial antibiotic treatment included amikacin sulfate, clindamycin
phosphate, and gentamicin sulfate. A single antibiotic was used in 5 patients
(13%); 2 antibiotics in 30 (77%); and 3 antibiotics in 4 (10%). The most frequent
antibiotic combinations (22 patients [56%]) were an aminoglycoside or third-generation
cephalosporin plus clindamycin, antistaphylococcal penicillin, and a first-generation
cephalosporin or fosfomycin. Treatment with clindamycin plus cefoperazone
sodium is recommended as soon as NF is diagnosed.
Surgical debridement with the patient under general anesthesia was performed
in 33 patients (85%). The number of surgeries ranged from 1 to 13 (mean number
per patient, 3.6). The number of days from admission to surgical debridement
ranged from 1 to 29 (mean, 5.42; median, 2). In 18 patients (46%), skin grafts
were used. The number of days in the hospital ranged from 1 to 130 (mean,
41.1). Seven patients (18%) died.
To find risk factors for death, a comparative analysis of the variables
was performed. Immunosuppression, delayed capillary refill, hypotension, hypothermia,
disseminated intravascular coagulation, and hypovolemic shock were statistically
significant factors that predicted the probability of death. Once risk factors
identified in the bivariate analysis were included in a multivariate analysis,
hypothermia, hypotension, and immunosuppression remained the significant predictor
factors of death (95% confidence intervals did not overlap 1; P<.001).
COMMENT
Necrotizing fasciitis is rare in children.10
It has been reported in 0.03% of hospitalization causes25
and in 0.08 per 100 000 children per year.13
Our 39 patients (1.34 cases per year) represented 0.018% of all our hospitalized
patients.
Necrotizing fasciitis is more common in middle-aged adults, without
sex, race, or geographic predilection.26 In
adults, the lower extremities are more frequently affected, followed by the
trunk and head.7, 27 In children,
most lesions are reported in the trunk.1, 10-13
In newborns, NF originates from omphalitis.28
In our series, the lower extremities constituted the most commonly affected
area (17 patients [44%]).
Necrotizing fasciitis in the genital area is known as Fournier gangrene.
It is more common in diabetic patients and in immunosuppressed males29 or after genital surgical procedures30
or rectal perforation.31 Fournier gangrene
is seldom reported in children.32-34
In our series, 5 patients had genital involvement. Of these, involvment was
primarily genital in 2, owing to an inadequate setting of a Foley catheter
tube in one and after an orchiopexy in the other. The remaining 3 cases resulted
from the extension of neighboring lesions (abdomen and thigh). In this group,
1 patient with immunosuppression died.
Location in the neck is a rare but severe presentation associated with
high mortality,35-36 owing to
carotid artery and mediastinal dissemination.37
Four of our patients presented with NF in the neck. Of these, one died of
tracheal compression and another of carotid rupture (both causes were diagnosed
at autopsy). The patient with tracheal compression presented with severe respiratory
failure. At admission, intubation was unsuccessful, and tracheostomy could
not be performed due to severe edema.
Predisposing factors vary with age. Diabetes is the main factor in adults,38 but other chronic diseases, such as hypertension,
peripheral vascular disease, renal failure, obesity, alcoholism, and malnutrition,
are important underlying factors.39 Nonsteroidal
anti-inflammatory drugs have been implicated as a predisposing factor,11 although the relationship remains controversial.40 Some cases in children have been associated with
immunosuppressive diseases such as acute lymphoblastic leukemia.10, 17, 20
In our series, half of the patients presented predisposing factors, the most
frequent being malnutrition in 14. Immunosuppression was a factor in 6 patients,
due to acute lymphoblastic leukemia in 3 and drug-induced in 3.
Initiating factors reported in the literature include minor injuries,3, 7-8,26-27,38
surgical and traumatic wounds,21, 26
contusion,41 and varicella.42-43
In a number of cases, initiating factors cannot be identified.7, 26-27
In newborns, omphalitis,1 circumcision,1, 44 and placement of electrodes for the
monitoring of vital signs1 have been reported
as initiating factors. In our series, initiating factors were determined in
85% of patients, the most frequent being varicella.
Clinical manifestations in NF start around a week after the initiating
event, with induration and edema, followed 24 to 48 hours later by erythema
or purple discoloration (Figure 1)
and increasing local fever.7 Pain is important
in the early stages, and sometimes crepitation can be found.3
Tissue necrosis with nerve involvement results in hyposensitivity or anesthesia.
Forty-eight to 72 hours later, the skin turns smooth, bright, and serous,
or hemorrhagic blisters develop (Figure 2). Without treatment, necrosis develops, and by the fifth or sixth
day, the lesion turns black with a necrotic crust (Figure 3). Removal of the crust shows fascial tissue and a brown
grayish secretion.7 Subcutaneous cellular tissue
is friable and easily removable. Sometimes the presence of gas (produced by
aerobic and anaerobic bacteria) is recognized through tissue crepitation.
This sign, although infrequent, is highly suggestive of NF.45
Necrosis of the superficial fascia is always more extensive than that indicated
by the extension of skin necrosis.46
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Figure 1. Necrotizing fasciitis on the third
day shows erythema and edema.
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Figure 2. Necrotizing fasciitis on the fifth
day shows initial epidermal necrosis and hemorrhagic and serous blisters.
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Figure 3. Necrotizing fasciitis on the seventh
day shows well-defined necrosis.
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Systemic signs and symptoms are a consequence of the toxic process and
septicemia. A high fever is disproportionate in relation to the size of cutaneous
lesion.7 Consciousness disturbance correlates
with the severity of the process.47 Multiple
organs and systems can be involved, and abscesses of the liver, lungs, spleen,
brain, and pericardium may develop.7, 27
Tissue edema may deplete the vascular volume and provoke hemoconcentration,
hypotension, obnubilation, and shock. Tachypnea, hyperglycemia (with osmotic
diuresis), and fever aggravate the hypovolemic state.48
Tissue bacteria are isolated in about 76% of cases.49
In our series, positive tissue cultures were found in 24 cases (62%). A polybacterial
cause of NF is well documented.26, 50
In our series, the isolates in 17 (71%) of 24 cases were polymicrobial.
Group A  -hemolytic streptococcus has been the most frequently
incriminated agent since Meleney's findings,4, 8, 38-39,51
and a recent increase in its frequency has been reported.52-55
Many other bacteria may be involved.10, 23, 29, 46, 49, 51, 56-65
Fungi such as Aspergillus,64
Mucoraceae,46 and Candida
albicans65 rarely are etiologic agents. Pseudomonas has been implicated as an important causal
agent in patients with neutropenia.16 In our
series, Pseudomonas was the main causal agent, always
in association with other bacteria. The results of gram stain should not be
used as a guide to therapy because of the polymicrobial nature of NF.48
The diagnosis of NF was suspected initially in only 11 (28%) of our
patients. Cellulitis was the most frequent initial diagnosis, made in 23 (59%)
of our patients. These findings suggest that the diagnosis of NF is often
overlooked and, consequently, that specific therapeutic measures are delayed.
Over time, the trend in our series was toward an improvement of the survival
rate.
In the presence of a soft tissue infection unresponsive to treatment
and with rapid health deterioration, NF should be suspected. The diagnosis
is confirmed during surgical debridement by the presence of liquid necrosis
of the superficial fascia.46 In doubtful cases,
the results of a frozen-section biopsy during surgery may confirm the diagnosis.63 Elements for histological diagnosis include necrosis
of the superficial fascia; leukocytic infiltrates with polymorphonuclear cells
predominant in fascia, subcutaneous fat tissue, and dermis; arterial and venous
fascial thrombosis; angiitis with fibrinoid necrosis; visible bacteria in
the fascia and dermis on results of gram stain; and absence of muscular damage.63 A skin biopsy was performed in 16 (41%) of our patients,
and the findings were in all cases compatible with the clinical diagnosis
of NF.
Anemia, found in 29 (74%) of our cases and reported in 70% to 90% of
cases in the literature,10, 26
is probably due to hemolysis. Leukocytosis was present in 25 (64%) and leukopenia
in 5 (13%) of our cases. Trombocytopenia,10, 48
longer coagulation time, hypofibrinogenemia, and circulating fibrin degradation
products can be a marker of disseminated intravascular coagulation.26 Disseminated intravascular coagulation was a complication
in 11 (28%) of our cases and was fatal in 5 of them. Abnormal results of liver
function tests,66 prerenal azotemia, hypocalcemia,
hypoalbuminemia,48 and an increased creatine
phosphokinase level47 may be present.
A differential diagnosis should be made with other infectious or necrotic
processes with similar appearance. Among the more benign infectious processes,
early cellulitis may present in a form similar to NF, but the edema in NF
is harder. Cellulitis and NF present with signs of toxicity, but cellulitis
responds to conventional treatment in 24 to 48 hours, whereas in NF, necrosis
will progress if surgical treatment is not initiated. Erysipelas presents
with well-defined erythematous edges, soft edema, and the absence of necrosis
and systemic toxicity.24 Gaseous gangrene produces
a quickly progressive myonecrosis that involves deep fascia with early crepitation,
severe local pain, and few cutaneous changes.67
Pyoderma gangrenosum has a slow evolution and is frequently associated with
ulcerative colitis, rheumatoid arthritis, and myeloma.68
In cutaneous necrosis caused by the extravasation of intravenous drugs, the
positive history findings are helpful.69 Ecthyma
gangrenosum is due to Pseudomonas aeruginosa and
consists of pustules with an erythematous base that burst in hours and turn
into punched, quickly progressive lesions with purpuric raised edges, more
frequently located in the anogenital region, axillae, abdomen, and legs of
children.70 Purpura fulminans often appears
after varicella and starts with ecchymotic areas in the extremities with inflammation,
hemorrhage, and necrosis.71 In our series,
cellulitis and purpura fulminans were the most frequent initial diagnoses.
Once vital signs are stable and the hydroelectrolytic balance is stabilized,
extensive debridement of necrotic tissue must be performed (Figure 4), and the procedure must be repeated as many times as needed.
Sudarsky et al39 reported a decrease in mortality
from 50% to 0% in selected patients with appropriate early treatment. Freischlag
et al72 concluded that mortality doubles when
surgery is delayed for more than 24 hours. Initially, the combination of clindamycin
and a third-generation cephalosporin that covers P aeruginosa seems adequate. Once culture findings and bacterial sensitivity are
obtained, antibiotics should be administered accordingly. Antibiotics alone,
because of their inability to reach the poorly vascularized and necrotic fascia,
have little effect if surgery is not performed.10
In our series, the median time from admission to surgery was 2 days. Owing
to severe multiple organ failure treated in the intensive care unit in a 4-year-old
boy (patient 28 in Table 1), the
time from admission to surgery was 29 days. Skin grafts should be applied
as soon as there is no evidence of infection and granulation tissue appears.26, 48, 51 When indicated, total
parenteral nutrition must be given.21
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Figure 4. Necrotizing fasciitis after extensive
surgical debridement of necrotic tissue.
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The benefit of hyperbaric oxygen in NF remains controversial.73 Other poorly tested therapies include high doses
of intravenous immune globulin, granulocyte transfusion, granulocyte colony-stimulating
factor (in granulocytopenic patients),20 and
bovine thymic extract (Thymostimulin).74
Mortality rates in adults range from 8% to 100%.8, 26, 67
In newborns, the mortality rate can be as high as 87.5%.75
The average mortality in children ranges from 10% to 60%, with a mean of 20%.18 Most deaths are due to sepsis or multiorgan failure.
In our series, mortality was average (18%), mostly owing to infectious complications
(eg, sepsis, septic hepatitis, and pneumonia) or volemic alterations (disseminated
intravascular coagulation and hypovolemic shock). One patient died owing to
tracheal compression, and another, owing to carotid rupture.
In the multivariate analysis, immunosuppression, hypothermia, and hypotension
were the significant risk factors for death. Hypotension and hypothermia were
considered terminal events.
Sequelae were present in 29 (91%) of 32 survivers, most frequently unsightly
scars (23 patients [72%]) and deformity (18 [56%]). Other observed sequelae
included joint function limitation in 6 patients (19%), laryngeal stenosis
in 1 (3%), and toe amputation in 1 (3%).
CONCLUSIONS
Necrotizing fasciitis is a severe multisystemic disorder with prominent
cutaneous features that can compromise life if diagnosis and treatment are
delayed. After the first month of life, the location of lesions is the same
in adults and children. The most frequent predisposing factor in our patients
was malnutrition. In 19 children (49%), predisposing factors were not identified.
The most frequent initiating factor was varicella. The most important risk
factor for death in our series was immunosuppression. On the basis of our
findings, antibiotic treatment with clindamycin plus cefoperazone sodium is
recommended as soon as NF is diagnosed. According to the findings of bacterial
cultures and antibiograms, this regimen may be modified. Surgical debridement
should be performed as soon as the patient's condition is stabilized.
AUTHOR INFORMATION
Accepted for publication June 29, 2001.
Corresponding author and reprints: Ramon Ruiz-Maldonado, MD, Insurgentes
Sur 3700-C, Colonia Insurgentes Cuicuilco, Mexico City, Mexico CP 04530 (e-mail: rrm{at}servidor.unam.mx).
From the Departments of Pediatric Dermatology (Drs Fustes-Morales,
Duran-Mckinster, Orozco-Covarrubias, Tamayo-Sanchez, and Ruiz-Maldonado) and
Research (Dr Gutierrez-Castrellon), National Institute of Pediatrics, Mexico
City, Mexico.
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