Necrotizing Fasciitis in an HIV- Infected Patient

Letters to the Editor

responded satisfactorily when the primary disease was treated with HAART.

SSumitumit SSen,en, PParnaarna BBhaumikhaumik Department of Dermatology, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India

AAddressddress fforor ccorrespondence:orrespondence: Dr. Sumit Sen, Department of Dermatology, North Bengal Medical College and Hospital, Susrutnagar, District Darjeeling, West Bengal, India. E-mail: [email protected]

RREFERENCESEFERENCES

1. Dhar S, Jain S, Verma G, Tanwar R. Disseminated and atypical Figure 1: Multiple giant molluscum with central one showing crater like depression Molluscum contagiosum in an AIDS patient. Indian J Dermatol Venereol Leprol 1996;62:331-2. 2. Raynaud- Mendel B, Janier M, Gerbeka J. Dermatologic findings in HIV-1 infected patients a prospective study with emphasis on CD4 + cell count. Dermatology 1996;192:325-8. 3. Mansur AT, Goktay F, Gunduz S, Serdar ZA. Multiple giant Molluscum contagiosum in a renal transplant recipient. Transpl Infect Dis 2004;6:120-3. 4. Calista D. Topical cidofovir for severe cutaneous human papilloma virus and Molluscum contagiosum infection in patients with HIV/AIDS: A pilot study. J Eur Acad Dermatol Venereol 2000;14:484-8. 5. Scolaro MJ, Gordon P. Electron beam therapy for AIDS related Molluscum contagiosum lesions: Preliminary experience. Radiology 1999;210:479-82. 6. Nelson MR, Chard S, Barton SE. Intralesional interferon for the treatment of recalcitrant Molluscum contagiosum in HIV Figure 2: Nine months after HAART, showing disappearance of antibody positive individuals: A preliminary report. Int J STD disfi guring giant Molluscum contagiosum AIDS 1995;6:351-2. 7. Liota E, Smith KJ, Bukley R,Menon P, Skelton F. Imiquimod become basophilic, as seen in our case. Histological variants therapy for Molluscum contagiosum. J Cutan Med Surg seen in immunocompromised patients are pseudocystic and 2000;4:76-82. polypoidal types.[3] These were not seen in our patient’s 8. Hicks CB, Myers SA, Giner J. Resolution of intractable biopsy. Molluscum contagiosum in a human immunodeficiency virus infected patient after institution of anti-retroviral therapy with ritonavir. Clin Infect Dis 1997;24:1023-5. Cidofovir (1-3%) cream or ointment[4] and electron beam therapy[5] have been used effectively to treat extensive lesions in the immunosuppressed but are not easily available. Facial mollusca of the giant type and especially those found NNecrotizingecrotizing fasciitisfasciitis iinn aann HHIV-IV- in HIV-infected patients do not respond well to treatment. iinfectednfected ppatientatient Intralesional interferon used in resistant facial mollusca[6] and topical imiquimod[7] were avoided as they were costly. Therapies targeted at boosting the immune system in the Sir, immunocompromised have proven to be most effective in Necrotizing fasciitis is a life-threatening, progressive, rapidly such cases.[8] spreading, inflammatory infection of the deep fascia, with secondary necrosis of the subcutaneous tissues and usually Our case had a number of atypical and giant mollusca on associated with the trauma and immunodeficiency. We the forehead in addition to genital lesions. Some of the present a case of necrotizing fasciitis in an HIV-infected lesions on the forehead mimicked keratoacanthomas. They patient.

268 Indian J Dermatol Venereol Leprol | May-June 2008 | Vol 74 | Issue 3 Letters to the Editor

Figure 1: Single large ulcer (5 cm × 8 cm) with necrotic margins, Figure 2: Appearance two weeks after grafting slough on fl oor with surrounding hemorrhagic and ecchymotic skin in the left inguinal region

A 27-year-old unmarried male presented with painful Fournier’s gangrene, streptococcal gangrene, and flesh- raw lesions over the left inguinal region since 3 days. It eating bacterial infection are the other terms used. It is of started with a painful left inguinal swelling associated with two types, depending on the organisms isolated. Type 1 high-grade fever followed by the formation of blisters, is polymicrobial, usually caused by aerobic and anaerobic which ruptured spontaneously to form raw lesions. He organisms, while Type 2 is caused by Group A β-hemolytic was non-diabetic and gave no history of trauma or invasive streptococci, either almost always alone or in combination procedure. with other species.[2] Our case was of Type 2. The organism enters into the subcutaneous space through a disruption of On examination, there was a single large ulcer with necrotic the overlying skin either by trauma or surgery, or lympho- slough on the floor, irregular edges, and the surrounding hematogenous spread from a distant site, but rarely infection skin showing ecchymosis [Figure 1]. A differential diagnosis can occur over healthy skin.[3] of cutaneous vasculitis, necrotizing fascitis, pyoderma gangrenosum, and pyomyositis was entertained and the Necrotizing fasciitis has reported cumulative mortality patient was investigated. of 34%, with the range being 6 to 76%.[4] In suspected necrotizing fasciitis, a full-thickness biopsy, particularly if His hemogram, liver function tests, renal function tests, combined with more extensive surgery, has been shown to electrocardiogram, coagulation profile, and X-ray chest correlate with an improved outcome.[5] were normal. Erythrocyte sedimentation rate was 30 mm at the end of one hour and ELISA for HIV-I was positive. Pus Clinical suspicion of necrotizing fasciitis should be high culture grew beta hemolytic streptococci and Pseudomonas because early diagnosis and early treatment, including aeruginosa. Blood culture was normal and CD4 count was wide excision and debridement, along with antibiotics 350 cells/µl. Sonography of the abdomen showed external decrease patient morbidity and mortality in this otherwise iliac lymphadenopathy and mild splenomegaly. Anti-nuclear poorly-prognostic condition.[6] In immunocompromised antibody and pathergy test were negative. On histopathology, host, particularly, it becomes mandatory to biopsy any there was a dense infiltrate of polymorphonuclear cells necrotic cellulitic lesions and to be alert to the possibility in the dermis and subcutaneous tissue mostly around the of a wide range of bacterial, viral, fungal, and even parasitic blood vessels. Surgical debridement was done and he was infestations.[2] started on injectable cefotaxime (1 gm iv 8 hrly), amikacin (500 mg iv 12 hrly), and metronidazole (500 mg iv 8 hrly) along with daily dressing. Split-thickness skin grafting was AAmarmar SSurjushe,urjushe, ReshamResham Vasani,Vasani, done with significant healing in 2 weeks’ time [Figure 2]. MMinalinal TThakrehakre1, DD.. GG.. SSapleaple Department of Dermatology, Venereology and Leprosy, Grant Medical 1 [1] College and Sir JJ Group of Hospitals, Mumbai. Department of Necrotizing fasciitis was first described by Wilson. Hospital Pathology, Grant Medical College and Sir JJ Group of Hospitals, gangrene, progressive bacterial synergistic gangrene, Mumbai, India

Indian J Dermatol Venereol Leprol | May-June 2008 | Vol 74 | Issue 3 269 Letters to the Editor

AAddressddress fforor ccorrespondence:orrespondence: Dr. Amar Surjushe, Department of Other causes of genital elephantiasis like infections and Dermatology, Venereology, and Leprology, Grant Medical College and [3,4] Sir JJ Groups of Hospitals, Mumbai - 400 008, India. malignancies are very rare. E-mail: [email protected] A 45-year-old man, father of four, with swelling of scrotum RREFERENCESEFERENCES and penis of about 2 months duration was referred by a surgeon. Onset was sudden and within 2 weeks he developed 1. Wilson B. Necrotizing fasciitis. Am Surg 1952;18:416-31. 2. Weinberg AN, Swartz MN, Tsao H, Johnson RA. Fitzpatrick’s a large swelling of penis and scrotum. He only had a feeling dermatology in general medicine. In: Freedberg IM, Eisen of heaviness and was depressed due to the embarrassing AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI, editors. Soft condition. There was no history of injury, operation, or tissue infections: Erysipelas, cellulitis, gangrenous cellulitis radiation prior to the onset. He had a large number of pus- and myonecrosis. 6th ed. New York: McGraw- Hill Publishing filled eruptions on both legs with fever, about 8 weeks prior Division; 2003. p. 1883-95. to the onset. He was treated by a doctor (non-dermatologist) 3. Melish ME, Bertuch AA. Bacterial skin infections. In: with oral and topical antibiotics. All lesions had healed in Feigin RD, Cherry JD, editors. Textbook of pediatric 10-15 days leaving behind scars. There was no history of infectious diseases. 4th ed. Philadelphia: W.B. Saunders Company; 1998. p. 741-52. extramarital sexual contact or genital ulcer disease. His wife 4. Mchenny CR, Piotrowski JJ, Pertrinic D, Malagani MA. was apparently healthy. Determinants of mortality in necrotizing soft tissue infections. Ann Surg 1995;221:558-65. Clinically, he did not have lymphadenopathy. General and 5. Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest systemic examinations were essentially normal. Genital 1996;110:219-29. examination revealed a cold, non-tender, large-curved penis 6. Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, measuring 8 inches in length and 5 inches in circumference, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: A retrospective study. looking like a “saxophone” [Figure 1]. There was no evidence Am Surg 1998;64:397-401. of ulcer, scar, or inflammation. The scrotum was huge and its contents could not be palpated. Both weighed about 1.0 kg. Transillumination test of scrotal swelling was negative. Left side of his lower abdomen and adjacent area of left UUnusualnusual causecause ofof saxophonesaxophone thigh had extensive postburn scars, but no edema. Both shins and legs had large number of scars without any sign ppenisenis of inflammation.

On the basis of history and clinical findings, a diagnosis Sir, of secondary lymphedema of penis and scrotum with Lymphedema is the occurrence of chronically swollen “saxophone” deformity was made. In this case, genital extremities or rarely the genitals due to inadequate lymphedema was secondary to bacterial infection, probably drainage of interstitial fluid by the lymphatics. Primary due to Staphylococcus aureus, but peculiarly the lymphedema lymphedema is uncommon and has female predominance. It may be congenital or familial (Milroy’s disease) or idiopathic appearing either at puberty (precox), or after 35 years of age (tardum).[1,2] Secondary lymphedema caused by obstruction of lymphatic flow due to destruction of lymphatics by various infections is relatively common. In India, secondary lymphedema is synonymous with filariasis.[1] Other causes include surgical removal of lymph nodes or their destruction by radiation fibrosis and malignant cell infiltration.[2]

Genital elephantiasis though uncommon is an important medical problem occurring in the tropics. It causes not only a major physical disability, but also extreme mental anguish. In the majority, filariasis is the cause but bacterial sexually transmitted infections (STIs) like lymphogranuloma Figure 1: Genital lymphedema leading to saxophone penis with venereum and donovanosis form a significant number. scars in groins

270 Indian J Dermatol Venereol Leprol | May-June 2008 | Vol 74 | Issue 3