Necrotizing Fasciitis: A Comparative Analysis of 56 Cases Jacob Ndas Legbo, MBBS, FWACS, FMCS, FRCSEd, FICS and Bello Bala Shehu, MBBS, FRCSI, FWACS Sokoto, Nigeria
Background: The term necrotizng fasciitis (NF) is now used in a generic sense to include all diffuse necrotizing soft-tissue infections except gas gangrene. It is a synergistic, polymicrobial softtissue infection associated with rapid progression, extensive necrosis, profound systemic toxemia, considerable morbidity and a high mortality rate. Although the disease is no respecter of age and affects a wide age group, adults are known to be more commonly affected than children. Aims: To highlight the differences and similarities in the modes of presentation and results of intervention of NF in children and adults. Patients and Methods: A four-year prospective descriptive analysis of all consecutive patients with NF (excluding cancrum oris and Fournier's gangrene) treated at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, from January 2001 to December 2004. Results: A total of 56 patients were treated of which 32 (57.1%) were children 15 years. There were 31 males and 25 females, giving the male-to-female ratio of 1.2:1; the corresponding ratios for children and adults were 1.7:1 and 1.1:2, respectively. The age ranged from six days to 70 years (mean 19.9 years). Trauma and minor skin infections were the main precipitating factors. The total body surface area (BSA) involved ranged from 1-16% (children 2-16%, adults 1-7%) with a mean of 4.3% (children 5.9%, adults 2.7%). The trunk was the most commonly involved anatomical region of the body (50.0%o) in children, while in adults it was the lower limb (54.2%). In both children and adults, infection was mainly polymicrobial. The most common mode of wound resurfacing was by second intention in children (46.9%) and split-thickness skin grafting (STSG) in adults (37.5%). Septicemia was a common complication in both age groups. Mortality was 9.4% and 16.7% among children and adults, respectively. Conclusion: NF is more common in children than adults in northwestern Nigeria. Early recognition, aggressive surgical treatment and supportive therapy remain the essential keys to success.
Key words: necrotizing fasciitis * children * adults aggressive treatment 1692 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
© 2005. From the Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigena. Send correspondence and repnnt requests for J Nat! Med Assoc. 2005;97:1692-1697 to: Jacob Ndas Legbo, MBBS, FWACS, FMCS, FRCSEd, FICS, Plastic & Reconstructive Surgery Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto 840001, Nigena; phone: +234 (0) 8035868790; e-mail:
[email protected]
INTRODUCTION In 1952, Wilson coined the term necrotizing fasciitis (NF) to describe a rapidly progressive inflammation and necrosis of subcutaneous tissue and fascia.' Before then, the disease had been described under various nomenclature, such as hemolytic gangrene, acute streptococcal gangrene, gangrenous erysipelas, necrotizing erysipelas, suppurative fasciitis and hospital gangrene,23 just to mention a few. However, the term is now used in a generic sense to include all diffuse necrotizing softtissue infections except gas gangrene.4 Unlike in clostridial myonecrosis, the muscle is frequently unaffected and in the early stages, the skin stays intact.4-6 Contrary to the earlier belief that it was caused solely by hemolytic streptococci,7 NF is now known to be a clinical entity of polymicrobial and synergistic nature without any particular combination.2'6'8 9 The resultant effect is usually far more fulminant than the regular effect attributable to the individual pathogen.2 The actual incidence of the disease has not been elucidated, although most reviews reported 2-3 cases being seen in most major centers per year.2'6'8 Considered a rare entity, NF has been known to affect more adults than children and can be observed in a wide variety of clinical settings in both age groups.7'8"0"'6 The disease may start spontaneously or follow local infections, minor wounds or surgical procedures.9"2'5 Although it has been reported in healthy individuals, it is more likely in patients with underlying diseases, such as diabetes mellitus, hepatorenal disease, cancer, HIV/AIDS or those undergoing organ transplantation.'4"'7 The diagnosis of NF is mainly clinical. It has a varied spectrum of presentation, ranging from simple cellulitis to septic shock VOL. 97, NO. 12, DECEMBER 2005
NECROTIZING FASCIITIS
and multiple organ dysfunction/failure.'8"9 Pain, fever or toxemia, which is out of proportion to the local signs (type and size of wound) is a hallmark in diagnosis.5'20 However, most cases run a fulminant course and are often associated with severe systemic inflammatory response syndrome (SIRS). 12,18,21-23 The keys to successful patient treatment of NF rest on early recognition, adequate resuscitation, broad-spectrum antibiotic therapy, radical surgical debridement and supportive care. The goal of surgery is to debride all necrotic soft tissue and fascia in order to halt the progression of the disease and aid speedy recovery.6 NF is associated with high morbidity and mortality if appropriate treatment is not offered in good time. It results in prolonged hospital stay and multiple surgical procedures. This has financial consequences, especially in countries where healthcare services are on a cash-and-carry basis, the cost being borne solely by the patients. Over 50% mortality has been reported.'8 Sporadic case reports and a few case series have been documented worldwide on NF. In this report, we present our experience in managing 56 consecutive children and adults in a Nigerian Teaching Hospital over a four-year period. The modes of presentation and outcome of management are compared and contrasted. This report represents one of the largest single series ever presented on NE
PATIENTS AND METHODS This is a four-year prospective descriptive study of all consecutive patients with NF treated at the Usmanu Danfodiyo University Teaching Hospital, Table 1. Anatomical distribution of lesions
Children % Adults % Total % n=32 n=24 n=56 9 16.1 Head/neck 9 28.1 Trunk 16 50.0 3 12.5 19 33.9 4 16.7 1 1 19.6 Upper limb 7 21.9 Lower limb 4 12.5 13 54.2 17 30.4 2 Perineum 6.3 2 20.8 4 7.1 Buttocks 5 8.3 5 8.9
Region
Sokoto, from January 2001 to December 2004. Approval for the study was obtained from the hospital's ethical committee on research. Permission to include the patients in the study was sought from each patient or their parents, and 100% participation was obtained from all the patients who presented within the study period. The study included all patients with diffuse necrotizing soft-tissue infections, according to the known standards of classification of soft-tissue infections.4 Patients with cancrum oris (noma) or Fournier's gangrene were excluded. This is because patients with the former are being managed in a specialized hospital built for that purpose in the same city, while those with the later are being managed mainly by the urologists in our center. All the patients were admitted and resuscitated. Each patient was thoroughly evaluated at initial assessment to determine the exact nature of the infection and ascertain the involvement, or otherwise, of other systems. This included detailed clinical evaluation (plus nutritional assessment), clinical photography, relevant microbiological, hematological, immunological, chemical, radiological and histological investigations. Blood samples, surface swabs and tissues were subjected to aerobic cultures only. Standard clinical (including anthropometric) Table 2. Cultural characteristics of isolated organisms Bacteria S. aureus
Children % Adult % Total % n=24 n=32 n=56 23 71.9 11 45.8 34 60.7
Streptococcus 19 Pyogenes
59.4
7
29.2 26 46.2
E. coli
15
46.9
6
25.0 21 37.5
P. aeruginosa 12
37.5
17
70.8 29 51.8
Klebsiella species
8
25.0
10
41.7 28 50.0
Nil growth
1
3.1
4
16.7
5
8.9
Table 3. Number of major debridements undertaken
Number of Debridements Nil 1 2 3 4
Children n=32 23 7 2 _
%
Adults n=24
7
Total n=56
%
71.9 21.9 6.3
2 10 7 4 1
8.3 41.7 29.2 6.7 4.2
2 33 14 6 1
3.6 58.9 25.0 10.7 1.8
-
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NECROTIZING FASCIITIS
and laboratory measures were used to assess the nutritional status. Broad-spectrum antibiotics were administered pending results of culture and sensitivity. Tetanus toxoid was also administered. Wounds were cleaned regularly with hydrogen peroxide, irrigated with normal saline and dressed with natural honey. Nutritional, physical and other forms of rehabilitation were instituted when necessary. Major surgical debridements were carried out in the operating room under general anesthesia and subsequently repeated when necessary. Wound resurfacing was by second intention, direct suturing, split-thickness skin grafting (STSG) or flap cover depending on the nature of the wound and other variables that each patient presented with. All necessary information on each patient was entered into a proforma and later transferred into the computer for analysis.
RESULTS Over the four-year period, a total of 56 patients were treated, out of which 32 (57.1%) were children 15 years. There were 31 males and 25 females, giving the male-to-female ratio of 1.2:1; the corresponding sex ratios for children and adults were 1.7:1 and 1:1.2, respectively. The ages ranged from six days to 70 years (mean 19.9 years). Figure 1 shows the age/sex distribution of all the patients. The common presenting features in both age groups
were pain (100%), fever (children 78.1%, adults 37.5%), tissue necrosis with undermining and surrounding cellulitis/edema (100%) and jaundice (children 20.8%, adults 9.4%). One or more precipitating factors were identified in 30 (53.6%) patients (18 children, 12 adults), including trauma in 12 (21.4%), injection in seven (12.5%) and pustules/boils in 15 (26.8%) patients. One child had NF following colostomy for high anorectal anomaly, while a woman had it from radiotherapy for cancer of the cervix (Figure 2). In the remaining 26 (46.4%) patients, no precipitating factor could be identified. The premorbid conditions included malnutrition in 13 children. In adults, there were three patients with diabetes mellitus, three with lymphedema of the lower limbs and two with HIV The duration of symptoms ranged from 3-37 days (children 3-19 days, adults 5-37 days), with a mean of 9.9 days (children 6.4 days, adults 13.3 days). The total body surface area (BSA) involved ranged from 1-16% (children 2-16%, adults 1-7%), with a mean of 4.3% (children 5.9%, adults 2.7%). While the trunk was the most commonly involved anatomical region of the body (50.0%) in children (Figure 3), it was the lower limb in adults (54.2%). Table 1 shows the anatomical regions of the body affected in both children and adults. The infection was polymicrobial in 62.5% of patients (children 65.6%, adults 58.3%). The commonest offending organisms were staphylococcus aureus and pseudomonas in children and
Table 4. Modes of wound resurfacing
Children n=32 15
Direct suturing
46.9
Adults n=24 6
2
6.3
Split-thickness skin grafting
7
Local flap reconstruction
SAMA/died
Wound Resurfacing Healing by second intention
%
%
%
25.0
Total n=54 21
37.5
4
16.7
6
10.7
21.9
9
37.5
16
28.6
4
12.5
-
-
4
7.1
4
12.5
5
20.8
9
16.1
SAMA/died: signed against medical advice or died before wound resurfacing
Table 5. Complications
Complication
Septicemia Anemia Joint stiffness Measles Tetanus Chronic osteomyelitis
Children n=32 23 9 -
-
Adults n=24 9 13 3
1
3.1
-
-
-
-
-
-
1 1
4.2 4.2
7
71.9 28.1
7
37.5 58.2 12.5
Total n=56 32 22 3 1 1 1
7 57.1 39.3 5.4 1.8 1.8 1.8
NECROTIZING FASCIITIS
adults, respectively (Table 2). In five (8.9%) patients, no organism was isolated. In both children and adults, >35% of patients had multiple wound debridements (Table 3). The most common mode of wound resurfacing was healing by secondary intention in children (46.9%) and STSG in adults (37.5%), as seen in Table 4. Transfusion of whole blood was undertaken in 22 (39.3%) patients: 9/32 children (28.1%) and 13/24 adults (54.2%). The blood volume transfused ranged from 40-3,500 mls (children 40-1,050 mls, adults 1,000-3,500 mls), with a mean of 892.5 mls (children 355 mls; adults 1,430 mls). Septicemia was the commonest complication, as it was observed in 57.1% of patients (Table 5). The duration of hospital stay ranged from 3-126 days (children 14-96 days, adults 3-126 days), with a mean of 36 days (children 27.6 days, adults 44.3 days). Follow-up ranged from two weeks to 2.5 years (children: three weeks to six months, adults: two weeks to 2.5 years), with a mean of 5.4 months (children 52.4 days, adults 9.1 months). Overall mortality was 12.5% (seven patients), comprising three children (9.4%) and four adults (16.7%), resulting mainly from septicemia (five), tetanus (one) and cardiovascular complications of anemia (one).
Figure 1. Age/sex distribution of all patients 16 -14 * Males
Q Females
Z,, 2
121
8
0
E
n6 0 110
2 0
122-01 04-016
L
I60
Age (Years) i
|l-- s-.1
Figure 2. A 50-year-old woman with necrotizing fasciitis of the gluteal region following radiotherapy for cervical cancer
DISCUSSION The reported annual incidence of NF is 2-3 cases.2'6'8 Our yearly incidence of 14 cases, therefore, represents one of the highest ever reported worldwide; this might be a result of the general confusion surrounding the term NF4 and our inclusion of other necrotizing soft-tissue infections. Recently, Khan et al.24 reported about 20 cases in 15 months while evaluating the effect of high-dose quinolones therapy in patients with NE We have chosen 15 years as a criterion mark between children and adults only for the purpose of this study. This choice was predicated by the common practice in northwestern Nigeria to get females, or sometimes males, to marry and bear children before the age of 15 years. Our findings in this study contradict the earlier assertion by some authors6 that NF is predominantly a disease of the adult population. In this study, over half of the patients (57.1%) were children aged
