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Necrotizing Fasciitis Complicating Female Genital Mutilation: Case Report Abdalla A

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Necrotizing Fasciitis Complicating Female Genital Mutilation: Case Report Abdalla A EMHJ • Vol. 16 No. 5 • 2010 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Case report Necrotizing fasciitis complicating female genital mutilation: case report Abdalla A. Mohammed 1 and Abdelazeim A. Mohammed 1 Introduction Case report On examination the she was very ill; she had a temperature of 40.2 ºC, pulse Necrotizing fasciitis is a deep-seated in- A 7-year-old girl presented to Kas- of 104 beats per minute and blood pres- fection of the subcutaneous tissue that sala New Hospital on 2 March 2005 sure of 90/60 mmHg. There was exten- results in the progressive destruction of with high fever following FGM. The sive perineal and anterior abdominal fascia and fat; it easily spreads across the procedure had been done 7 days prior wall necrosis (Figure 1). The left labium fascial plane within the subcutaneous to admission in a mass female genital majus, the lower three-quarters of the tissue [1]. It begins locally at the site of cutting in the village during the first left labium minus and most of the mons the trauma, which may be severe, minor week of the school summer vacation. pubis were eaten away. The clitoris was or even non-apparent. The affected After the cutting, a herbal powder was preserved. There was extensive loss of skin becomes very painful without any applied to the wound. No antibiotic skin and subcutaneous fat of the right grossly visible change. With progression was given. During that period she ex- inguinal region. Superficial skin ulcera- of the disease, tissues become swollen, perienced high fever and difficulty in tion reached the umbilicus. often within hours. Skin colour may passing urine. When her condition de- After initial resuscitation, she was progress to violet and blisters may form, teriorated, her family decided to bring catheterized with a Foley catheter and with subsequent necrosis of subcutane- her to the hospital. intravenous ceftriaxone was given. ous tissues. Necrotizing fasciitis is caused by many types of bacteria such as group A streptococcus, Vibrio vulnificus, Clostrid- ium perfringens, Bacteroides fragilis, com- monly known as “flesh-eating bacteria”; Group A streptococcus is the most com- mon cause [2]. The disease has also been referred to as haemolytic streptococcal gangrene, Meleney ulcer, acute dermal gangrene, hospital gangrene, suppura- tive fasciitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area. Patients with necrotizing fasciitis typically have a high fever and appear very ill. Very severe cases progress within hours and the mortality rate is as high as 40% [3,4]. Here we report a rare case of necro- Figure 1 Case of necrotizing fasciitis: extensive perineal and anterior abdominal tizing fasciitis complicating female geni- wall necrosis is evident tal mutilation (FGM). 1Faculty of Medicine & Health Sciences, University of Kassala, Kassala, Sudan (Correspondence to: Abdalla A. Mohammed: [email protected]). Received: 23/02/08; accepted: 14/05/08 578 املجلة الصحية لرشق املتوسط املجلد السادس عرش العدد اخلامس Debridement of the wound was per- last type is not commonly practised in Treatment consisted of broad spec- formed under general anaesthesia. With Sudan. trum antibiotics and exploration of the repeated debridement and dressing, Most girls undergo FGM when they affected area under general anaesthesia. she showed progressive improvement. are between 7 and 10 years old [6]. Incision of fascia to relieve tension with Wound swab culture showed group A Almost all those who have undergone multiple sequential debridement was streptococcal growth that was sensitive it experience pain and bleeding. The in- done. She showed progressive improve- to the drug prescribed. tervention itself is traumatic as girls are ment and the catheter was removed After 7 days her family took her usually physically held down during the after 6 days. Skin grafting would have away from hospital and she was not procedure. Those who are cut often have been done if she had stayed to com- seen again. their legs bound together for several days plete treatment. However, her family or weeks. The immediate consequences removed her from hospital after 7 days that have been documented include se- and before this could be done. Discussion vere pain, shock, excessive bleeding, dif- Given her condition, it is likely that ficulty in passing urine, infections, death fibrosis and contractures of anterior We report a rare case of necrotizing and psychological consequences. Since abdominal wall muscles will result from fasciitis complicating FGM to highlight such complications are usually docu- the FGM. The external genitalia will also the danger of this practice. FGM is mented only when the girl or woman be defective causing dyspareunia and defined by the World Health Organiza- seeks hospital treatment, the true ex- difficult labour. This girl is at high risk tion, United Nations Children’s Fund tent of immediate complications is un- of being taken for repair of her defective and United Nations Family Planning known. Mortality rates due to FGM are circumcision outside health facilities. Association as “the partial or total re- not known due to underreporting, but moval of the female external genitalia or Usually parents will not reveal the Hoskin thought it to be high in regions other injury to the female genital organs identity of the practitioner, who is usually where FGM is practiced [7]. Women for cultural or other non-therapeutic an experienced traditional practitioner, a with FGM are significantly more likely to reasons” [5]. Four types of FGM are health worker (midwife or nurse), a doc- have obstetric complications compared recognized: type 1 involves excision of tor and sometimes female gynaecologist. with those without FGM [8]. the prepuce, with or without excision of In 2008, 2 female doctors (a gynaecolo- part or the entire clitoris; type II involves An estimated 89% of Sudanese girls gist and a community physician) wrote excision of the clitoris with partial or undergo the procedure [9]. in a famous daily newspaper advocating total excision of the labia minora; type In our case, the girl was brought to in favour of FGM and admitting that III involves excision of part or all of the hospital late, after her condition had de- they practised type 1 [10]. external genitalia and stitching/narrow- teriorated. As seen in the figure, she had We would like to highlight the dan- ing of the vaginal opening (infibula- undergone type I FGM, which is called ger of this procedure even if it is done in tion); and type IV pricking, piercing or by some “sunna” to give it a religious its simplest form and even if performed incising of the clitoris and/or labia – this reference. by medical practitioners. References 1. Catena F et al. Necrotizing fasciitis: a dramatic surgical emer- 7. Hosken F. The Hosken Report: genital and sexual mutilation of gency. European journal of emergency medicine, 2004, 11:44–8. females, 4th ed. Lexington, MA, Women’s International Net- 2. Giuliano A et al. Bacteriology of necrotizing fasciitis. American work, 1993:37. journal of surgery, 1977, 134:52–7. 8. Banks E et al. WHO study group on female genital mutilation 3. Taviloglu K et al. Idiopathic necrotizing fasciitis: risk factors and obstetric outcome. Lancet, 2006, 367(9525):1835–41. and strategies for management. American surgeon, 2005, 9. Safe Motherhood Survey 2001. Sudan, Federal Ministry of Health 71(4):315–20. (FMoH), Central Bureau of Statistics (CBS), and United Nation 4. Yanar H et al Fournier’s gangrene: risk factors and strategies for Population Fund (UNFPA), 2001. management. World journal of surgery, 2006, 30(9):1750–4. -Encouraging female circumci] تاصيل ختان اﻻناث. .Elbashier AA .10 5. Female genital mutilation: a joint WHO/ UNICEF/UNFPA state- sion]. Al-Sudani Newspaper, 4 February 2008:8 (Issue No. 801). ment. Geneva, World Health Organization, 1997. 6. Egypt Demographic and Health Survey, 1995. Cairo, Egypt, Na- tional Population Council and Calverton, MD, Macro Interna- tional, 2006:175. 579.
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