STUDY 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 Background: Necrotizing fasciitis (NF) is a severe, Results: We examined 39 patients with NF (0.018% of life-threatening soft tissue infection. General features all hospitalized patients). Twenty-one patients (54%) were and risk factors for fatal outcome in children are not boys. Mean age was 4.4 years. Single lesions were seen in well known. 30 (77%) of patients, with 21(54%) in extremities. The most frequent preexisting condition was malnutrition in 14 pa- Objective: To characterize the features of NF in chil- tients (36%). The most frequent initiating factor was vari- dren and the risk factors for fatal outcome. cella in 13 patients (33%). Diagnosis of NF at admission was made in 11 patients (28%). Bacterial isolations in 24 Design: Retrospective, comparative, observational, and patients (62%) were polymicrobial in 17 (71%). Pseudo- longitudinal trial. monas aeruginosa was the most frequently isolated bacte- ria; gram-negative isolates, the most frequently associated Setting: Dermatology department of a tertiary care pe- bacteria. Complications were present in 33 patients (85%), diatric hospital. mortality in 7 (18%), and sequelae in 29 (91%) of 32 sur- viving patients. The significant risk factor related to a fatal Patients: All patients with clinical and/or histopatho- outcome was immunosuppression. logical diagnosis of NF seen from January 1, 1971, through December 31, 2000. Conclusions: Necrotizing fasciitis in children is fre- quently misdiagnosed, and several features differ from those Main Outcome Variables: Incidence, age, sex, num- of NF in adults. Immunosuppression was the main factor ber and location of lesions, preexisting conditions, ini- related to death. Early surgical debridement and antibi- tiating factors, clinical and laboratory features, diagno- otics were the most important therapeutic measures. sis at admission, treatment, evolution, sequelae, and risk factors for fatal outcome. Arch Dermatol. 2002;138:893-899 ECROTIZING fasciitis streptococcal gangrene, synergistic necro- (NF) is a rare, rapidly tizing cellulitis, Meleney cellulitis, and oth- progressive, and poten- ers. In addition, Wilson8 differentiated NF tially fatal infection of the from disorders like erysipelas, cellulitis, superficial fascia and and clostridial myonecrosis with muscle subcutaneous cellular tissue.1,2 Necrotiz- involvement. At present, a popular syn- N 9 ing fasciitis is frequently polymicrobial, onym is flesh-eating bacteria disease. and the combination of aerobic and an- Series of NF in children are scarce and aerobic bacteria contributes to the quick include few cases,1,10-14 with less than 100 progression and severity of the disorder.3 in the literature.1,2,10-24 The present series Necrotizing fasciitis has been known of 39 cases is, to our knowledge, the larg- since antiquity.4,5 In 1871, Jones6 gave the est reported. From the Departments of first clinical description of “hospital gan- Pediatric Dermatology 7 grene.” In 1924, Meleney wrote a classic RESULTS (Drs Fustes-Morales, report on NF, emphasizing the impor- Duran-Mckinster, tance of early diagnosis and surgical treat- We found 39 patients with a diagnosis of Orozco-Covarrubias, ment to reduce mortality. In 1952, Wil- NF during the 30-year study period, rep- Tamayo-Sanchez, and 8 Ruiz-Maldonado) and Research son proposed the term necrotizing fasciitis resenting 0.018% of all hospitalized pa- (Dr Gutierrez-Castrellon), to replace terms like gangrenous erysip- tients. Of these, 21 (54%) were boys, and National Institute of Pediatrics, elas, hospital gangrene, acute cutaneous gan- 18 (46%) were girls. Ages ranged from 10 Mexico City, Mexico. grene, nonclostridial crepitant cellulitis, days to 15.5 years (mean ± SD age, 4.4 (REPRINTED) ARCH DERMATOL / VOL 138, JULY 2002 WWW.ARCHDERMATOL.COM 893 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 (44%), ie, septicemia in 10 (59%) of these and humeral osteomyelitis, febrile neutropenia, hemorrhagic vari- PATIENTS AND METHODS cella, septic arthritis, malnutrition, acute diarrhea, and disseminated intravascular coagulation in 1 patient each STUDY DESIGN of the remaining 7. Initial antibiotic treatment included amikacin sul- We performed a retrospective, observational, com- fate, clindamycin phosphate, and gentamicin sulfate. A parative, and longitudinal study. single antibiotic was used in 5 patients (13%); 2 antibi- otics in 30 (77%); and 3 antibiotics in 4 (10%). The most SAMPLE POPULATION frequent antibiotic combinations (22 patients [56%]) were an aminoglycoside or third-generation cephalosporin plus We included all clinical records of patients hospital- clindamycin, antistaphylococcal penicillin, and a first- ized in the National Institute of Pediatrics, Mexico generation cephalosporin or fosfomycin. Treatment City, Mexico, with a diagnosis of NF from January with clindamycin plus cefoperazone sodium is recom- 1, 1971, through December 31, 2000. We included all patients aged 1 day to 18 years of either sex with mended as soon as NF is diagnosed. a diagnosis of NF. Surgical debridement with the patient under gen- eral anesthesia was performed in 33 patients (85%). The STATISTICAL CONSIDERATIONS number of surgeries ranged from 1 to 13 (mean number per patient, 3.6). The number of days from admission to The sample size needed to be considered significant surgical debridement ranged from 1 to 29 (mean, 5.42; was calculated as 35 to 40 patients. We used a com- median, 2). In 18 patients (46%), skin grafts were used. mercial statistical software package (SPSS Base Sys- The number of days in the hospital ranged from 1 to 130 tem; SPSS Inc, Chicago, Ill) for data analysis. All stud- (mean, 41.1). Seven patients (18%) died. ied variables were analyzed in univariate form using To find risk factors for death, a comparative analy- t or ␹2 test (P≤.05 was considered significant). Sig- nificant factors in the univariate analysis to predict sis of the variables was performed. Immunosuppres- risk for death were included in a logistic regression sion, delayed capillary refill, hypotension, hypother- multivariate analysis. mia, disseminated intravascular coagulation, and hypovolemic shock were statistically significant factors that predicted the probability of death. Once risk fac- tors identified in the bivariate analysis were included in years±4.7 months). The number and location of le- a multivariate analysis, hypothermia, hypotension, and sions, preexisting conditions, initiating factors, bacte- immunosuppression remained the significant predictor rial isolations, complications, evolution, and sequelae are factors of death (95% confidence intervals did not over- shown in the Table. lap 1; PϽ.001). The signs and symptoms at the time of diagnosis were fever in 36 patients (92%), vomiting in 21 (54%), hypo- COMMENT tension and irritability in 13 (33%) each, prostration in 11 (28%), hyporexia in 8 (21%), altered consciousness Necrotizing fasciitis is rare in children.10 It has been re- in 6 (15%), impaired peripheral perfusion in 5 (13%), ported in 0.03% of hospitalization causes25 and in 0.08 per hypothermia in 2 (5%), and hypertension in 1 (3%). Lo- 100000 children per year.13 Our 39 patients (1.34 cases per cal signs and symptoms were pain, hard edema, and ery- year) represented 0.018% of all our hospitalized patients. thema in all patients; local warmth in 33 (85%); and func- Necrotizing fasciitis is more common in middle- tional limitation in 29 (74%). Ecchymoses and necrosis aged adults, without sex, race, or geographic predilec- were each recorded in 28 patients (72%), hemorrhagic tion.26 In adults, the lower extremities are more fre- blisters in 25 (64%), purulent secretion in 16 (41%), se- quently affected, followed by the trunk and head.7,27 In rous blisters in 14 (36%), local delayed capillary refill in children, most lesions are reported in the trunk.1,10-13 In 7 (18%), and crepitus in 4 (10%). newborns, NF originates from omphalitis.28 In our se- Serum laboratory findings showed hemoglobin lev- ries, the lower extremities constituted the most com- els ranging from 4.0 to 14.8 g/dL (mean level, 9.5 g/dL); monly affected area (17 patients [44%]). hematocrit levels, 12% to 48% (mean level, 29%); white Necrotizing fasciitis in the genital area is known as blood cell count, 300 to 72000 cells/µL (mean, 16552 Fournier gangrene. It is more common in diabetic pa- cells/µL); neutrophil levels, 18% to 87% (mean level, 59%); tients and in immunosuppressed males29 or after genital lymphocyte levels, 8% to 70% (mean level, 32%); mono- surgical procedures30 or rectal perforation.31 Fournier gan- cyte and eosinophil levels, within the reference ranges; grene is seldom reported in children.32-34 In our series, 5 bands, 0% to 33% (mean, 4%); and platelet count, 10 to patients had genital involvement. Of these, involvment 400 ϫ103/µL (mean, 188.4 ϫ103/µL). was primarily genital in 2, owing to an inadequate set- Results of radiographic studies performed in 13 pa- ting of a Foley catheter tube in one and after an orchio- tients (33%) showed soft tissue swelling in all and gas pexy in the other. The remaining 3 cases resulted from in 3 (8%). the extension of neighboring lesions (abdomen and thigh). Diagnoses at admission were cellulitis in 23 pa- In this