Critical Care: Fellow Case Report Poster - Critical Care II |

A Rare Presentation of Necrotizing Fasciitis of the Forehead and Eyelids FREE TO VIEW

Mohammed Siddiqui, DO; Marina Duran-Castillo, MD
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Pulmonary & Critical Care, Metrohealth Medical Center, Cleveland, OH

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):241A. doi:10.1016/j.chest.2016.08.254
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SESSION TITLE: Fellow Case Report Poster - Critical Care II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Necrotizing fasciitis (NF) is infrequent but highly lethal. We describe a rare case of a female patient who was successfully treated for NF of her scalp, forehead and bilateral eyelids.

CASE PRESENTATION: A 60 year old female with a history of alcohol abuse presented to our emergency room for level 3 trauma after a fall 3 days ago. She was noted to have peri-orbital/facial swelling and a scalp laceration. In the emergency room she acutely became hypotensive and hypoglycemic. Subsequently, she was admitted to the medical ICU requiring intubation and was treated for presumed anaphylactic shock. She deteriorated despite empiric antibiotic therapy and aggressive resuscitation. Two days into the admission, blood cultures resulted as Strep Pyogenes. A week later, purulent drainage from her swollen eye lids and worsening facial edema was noted. Immediately, she was taken to the OR for drainage of her wounds. Wound culture from the scalp and eye lid resection grew Strep. Agalactiae sensitive to vancomycin. She was diagnosed with necrotizing fasciitis of the scalp/forehead and bilateral upper/lower eye lids with severe septic shock. Over the next couple weeks, she underwent multiple surgical debridements requiring extensive reconstruction with continued antibiotic therapy. She was discharged home on prolonged antibiotic therapy. Despite surviving our patient has significant facial disfigurement.

DISCUSSION: At onset, necrotizing fasciitis is difficult to differentiate from other superficial skin infections. Studies have shown that only 15 to 30% of patients with NF have an accurate admitting diagnosis. The organisms commonly cultured in necrotizing infections are combinations of staphylococci, streptococci, and clostridium species. The mainstay of treatment for NF involves prompt surgical debridement, source control, and antimicrobials. Typically, the extremities and abdominal wall are involved, but NF of the face is extremely rare, as less than 50 cases have been reported in the literature.

CONCLUSIONS: It is important to have a high clinical suspicion for necrotizing fasciitis, as prompt recognition and surgery is imperative in preventing significant morbidity and mortality.

Reference #1: Cenk F, Hakan A. Necrotizing fasciitis of the scalp. Turkish Journal Surgery. 2005;11(1):69-72

Reference #2: Elliott D, Kufera. “The microbiology of necrotizing soft tissue infections.” American Journal of Surgery. Vol.179:361-366,2000

Reference #3: Goldstein E, Anaya. Necrotizing Soft-Tissue Infection: Diagnosis & Management. Clin Infect Dis.(2007)44(5)

DISCLOSURE: The following authors have nothing to disclose: Mohammed Siddiqui, Marina Duran-Castillo

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