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Notes on Practice: Necrotizing Fasciitis: A Diagnostic and Management Challenge
Background
Necrotizing fasciitis has been defined as a rapidly progressive disease characterized by extensive necrosis of skin, fascia, and subcutaneous tissue.1-3 If not diagnosed promptly, it can be severe and potentially life-threatening.4-6 The first reportable cases of vulvar necrotizing fasciitis were found in 1972 in the obstetric and gynecologic literature.7,8
The most commonly identified organisms found in necrotizing fasciitis are Escherichia coli, Bacteroides, Streptococcus, Enterococcus, Staphylococcus, Proteus, Pseudomonas, and Klebsiella.1,3,9
Risk factors commonly associated with this soft tissue infection are: over 50 years of age, hypertension with arteriosclerosis, diabetes, obesity, smoking, previous radiation, renal failure, and operative trauma.1,3,7 Early diagnosis and adequate debridement are crucial to overall survival. The literature suggests that women with diabetes may be predisposed to vulvar necrotizing fasciitis that can begin as a simple abscess.10,11
Hyperbaric oxygen (HBO) has been used to accelerate healing by stimulating angiogenesis and collagen deposition. Tissue healing is enhanced by HBO in ischemic bone and soft tissue through increased osteogenesis and bone remodeling, fibroblast proliferation, collagen formation, and capillary growth into avascular tissue areas.9,12
Case History
Ms. N was a 51-year-old female who presented to the emergency room on May 30, 2001 complaining of cough, fever, chills, and shortness of breath of a 2-week duration. Her temperature at time of admission was 101.5 degrees F. She initially was admitted to the Internal Medicine Service for evaluation and management with findings of congestive heart failure and bilateral pleural effusions. She was also newly diagnosed with diabetes mellitus with a fasting blood sugar of 374 mg/dL and a random blood sugar of 300+. Her Hg A1C was 10.8; she was managed with insulin, given her acute presentation, but transitioned to metformin as an outpatient.
Ms. N had been smoking for 30 years, presently consuming 1.5 packs every 2 days. She was not on any prescribed medications and was not taking any over-the-counter medications.
On her third hospital day, Ms. N complained of vulvar pain while sitting. One week before admission, she had noticed a pustule on her right inner thigh that had since enlarged and become very tender to touch. A pustule measuring 0.5 cm with significant erythema and crepitus into the labia and vulva was noted on examination.
She also reported a history of recurrent inguinal "cysts" over the past 2 to 3 years that she lanced at home with apparent relief. Approximately 4 cm from the anal region, a draining sinus tract with purulent effluent was noted. No evidence of a fistula in ano or rectal communication was revealed via rectal exam. Laboratory reports indicated a white blood count of 27.6. The patient was also tachycardic. The findings were suggestive of perineal/vulvar necrotizing fasciitis.
Ms. N was immediately taken to surgery and the necrotizing soft tissue and fascial infectious process was resected 2 cm inferior to the perineal sinus tract. The process continued along the right perineum, affecting the right labia majora and requiring resection of the labia majora. The process continued superiorly above the symphysis pubis affecting the right mons, which was also resected until healthy tissue was evident. The purulent process terminated in the right lower quadrant superficially and was resected completely. The resected tissue was sent to Pathology.
Diagnosis
The pathology report confirmed necrotizing fasciitis of the vulva, skin, and subcutaneous tissue. The contributing organisms identified were Prevotella bivia, Prevotella melaninogenicus, Streptococcus milleri group, and Streptococcus agalactiae Group B, beta hemolytic.
Management
Ms. N was transferred to the ICU postoperatively because she was unable to be extubated. Within 48 hours, she was extubated. Her hospital course was long and complicated, involving daily aggressive debridements and dressing changes. She received IV antibiotics (penicillin, clindamycin, gentamycin, and unasyn) for a 2-week course and was also treated with ketoconazole for a fungal rash.
A consult to the wound clinic was received from the OB/GYN doctors to evaluate wound status and current wound care. This clinician initially evaluated the patient on June 13, 2001 while she was still in the hospital (see Figure 1). Her wound measured 23.0 cm x 10.8 cm x 3.8 cm. Three tunnels were evident: one at 10 o'clock extending to 7.7 cm; a second at 12 o'clock extending to 6.8 cm; and a third at 2 o'clock extending to 5.7 cm. The wound base was down to the fascial level. Her ongoing wound care consisted of 1/4-strength Dakin's solution-moistened gauze packed into the dead space and covered with dry sterile dressings twice a day. Initial recommendations were to discontinue the Dakin's solution and twice daily dressing changes because the wound base was red with no apparent necrotic tissue. A wound care plan was developed to include daily visits to the clinic until a family member could be trained to do the dressing changes at home.
The patient's initial visit to the wound clinic was on June 18 for dressing changes. At her first visit to the clinic, this clinician discussed treatment modalities with her, including using HBO used as an adjunctive therapy. The patient chose not to have HBO so a different approach to wound healing was used in treating the wound. Becaplermin, a recombinant human platelet-derived growth factor, was used for topical administration. In addition, a calcium alginate wound-packing and thick absorbent pads were used to contain the effluent. The wound was irrigated with normal saline, using a 60-cc syringe at each visit, and wicked dry. Necrotic slough tissue was debrided as needed using a scalpel (see Figure 2). Becaplermin gel was applied in a thin layer to the wound base. A normal saline-moistened gauze roll was loosely packed into the dead space, covered with an absorbent pad, and secured with stretch net surgical panties. Ms. N also had candidiasis in the perineal area that was treated with clotrimazole 1% topical cream. Polaroid photographs and digital photos were obtained on a weekly basis with permission from the patient.
On June 25, 2001, the wound measured 23.0 cm x 9.5 cm x 3.6 cm (see Figure 3). Tunneling remained at 10 o'clock extending to 10 cm; 11 o'clock extending to 11 cm; and 12 o'clock extending to 7.1 cm. Granulation buds were apparent in the wound base. The patient's mother was instructed in the dressing change and agreed to do the dressing changes daily with follow-up visits in the wound clinic weekly. Wound measurements began steadily to decrease (see Table 1).
Hyperplasia was noted on several visits to clinic (see Figure 4a and 4b). Silver nitrate sticks were used on these areas. The wound was completely healed by September 13, 2001 (See Figure 5). The patient did not require any further surgical intervention and/or care.
In initiating a care plan for this patient, several factors were considered: 1) dressings should be easily applied and minimize pain; 2) treatment should be cost effective; and 3) dressings should facilitate wound healing. The direct cost of treating this patient in the wound clinic, including medication and dressings, was $1,695.54.
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