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Can Paronychia Cause a Remote Necrotizing Soft Tissue Infection?
The Journal of Emergency Medicine, Vol. 40, No. 1, pp. e11– e13, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2007.11.008
Clinical Communications: Adults
CAN PARONYCHIA CAUSE A REMOTE NECROTIZING SOFT TISSUE INFECTION? Julian E. Losanoff,
MD,*
Anne E. Missavage,
MD,†
Paul Linneman,
RN,‡
and Boyd E. Terry,
MD‡
*Department of Surgery, Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, †Department of Surgery, Michigan State University, Lansing, Michigan, and ‡Department of Surgery, University of Missouri-Columbia, Columbia, Missouri Reprint Address: Julian E. Losanoff, MD, John D. Dingell VAMC (11S), 4646 John R. Street, Suite 400, Detroit, MI 48201
e Abstract—Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome. © 2011 Elsevier Inc.
extremity. Cultures reveal predominantly Gram-positive aerobes (62%), including Streptococci, in 29.5% of the patients (4). Treatment options for paronychia include warm-water soaks, oral antibiotic therapy, and surgical drainage (5). Untreated paronychia can lead to significant morbidity, especially in immunocompromised patients. Involvement of the adjacent tendons, joints, bone, and soft tissues is rarely seen; treatment requires an individualized approach that is guided by both the extent of infection and underlying condition (4 – 6). We present our recent experience with necrotizing soft tissue infection (NSTI) of the chest wall, abdominal wall, and thigh, probably resulting from paronychia in a previously healthy patient.
e Keywords—paronychia; chest wall; abdominal wall; extremities; necrotizing fasciitis; necrotizing infection; complications; surgery
INTRODUCTION
CASE REPORT
Paronychia affects the soft tissue folds surrounding the nail and is considered one of the most common infections of the extremities. Predisposing factors include overzealous manicuring, nailbiting, diabetes mellitus, and occupations in which the hands are frequently immersed in water. Paronychias also have been reported in association with a variety of medications, including antiretroviral therapy for human immunodeficiency virus infection (1–3). A recent trial found that the condition affects 1% of the patients who present to the Emergency Department with surgical infection of the hand and upper
A 39-year-old previously healthy woman presented to the Emergency Department with a vesicular rash affecting the right chest and flank and the left thigh, increasing pain, pyrexia, and general malaise. The patient’s past medical history was significant for an episode of paronychia affecting multiple fingers that was treated by her family physician. The diagnosis had been confirmed by a consulting dermatologist. Culture from the lesions grew Streptococcus pyogenes susceptible to the prescribed local and systemic antibiotics. The paronychia completely resolved in less than 2 weeks, however, a simul-
RECEIVED: 19 December 2005; FINAL ACCEPTED: 22 May 2007
SUBMISSION RECEIVED:
20 March 2007;
e11
e12
taneous vesicular rash involved the right chest and flank and the left thigh. The patient’s condition worsened rapidly. None of the patient’s family had a history of sore throat. The vital signs included surface temperature of 39°C, blood pressure 90/50 mm Hg, pulse 140 beats/min, and respirations 28 breaths/min. Examination of the respiratory system revealed a normal oropharynx and coarse breath sounds bilaterally. The abdomen was unremarkable. Laboratory studies were significant for a leukopenia of 1400/mm3 and coagulopathy (international normalized ratio 2.8 and a platelet count of 42,000 per microliter). Human immunodeficiency virus testing was negative. The affected areas measured approximately 2 ⫻ 2 cm each and were warm, markedly edematous, and extremely tender. Necrotizing soft tissue infection was suspected. An Infectious Disease consultation was obtained. A left subclavian central line was placed through which parenteral fluids, imipenem, clindamycin, and high doses of penicillin were started. No peripheral lines were used. Necrotizing soft tissue infection was suspected, and the patient was brought to the operating room. Exploration of the affected areas revealed foulsmelling brownish exudate and necrosis of the fat, fascia, and superficial muscles extending beyond the operative area. The affected skin was excised. The necrotic fat, fascia, and muscles were thoroughly debrided and excised until healthy, bleeding tissue with normal color surrounded the surgical margins. The wounds (Figures 1, 2) were packed and the patient was transferred to the intensive care unit, where she required ventilatory and enteral nutritional support. Culture from the excised tissue specimens grew S. pyogenes susceptible to the prescribed antibiotics. Histology from the operative specimens was
J. E. Losanoff et al.
Figure 2. Necrotizing infection of the left thigh.
consistent with streptococcal necrotizing soft tissue infection affecting all tissue layers. Over the next 10 days, intensive bedside wound care with pulse irrigation and debridements were performed to remove more necrotic fat and fascia. The remaining muscles remained intact. Despite the successful wound care, the patient continued to have persistent spiking fevers. Physical examination revealed multiple deep tender areas along both the cephalic veins. A clinical diagnosis of septic thrombophlebitis was made and excision of the veins performed, with rapid resolution of the fever. Cultures from the veins grew S. pyogenes. Histology showed severe neutrophilic leukocyte infiltration of the veins, with abscesses in thrombi consistent with streptococcal phlebitis. Four weeks after admission to the hospital, the chest and flank wounds were successfully treated with split thickness skin grafts. All other wounds were closed primarily. The patient was last seen 3 months after discharge from the hospital. She was free of infection, and had no functional deficit in the areas of NSTI. DISCUSSION
Figure 1. Postoperative photograph demonstrating the extent of necrotizing infection in the chest and right flank.
NSTI is a rare, rapidly progressive infectious process primarily involving the fascia and the subcutaneous tissue. Angiothrombotic microbial invasion of the microcirculation and liquefactive necrosis rapidly progress and destroy the tissue planes. It is a life-threatening infection that is uncommon, with approximately 500 –1500 cases reported in the United States annually (7). The progression of the disease is typically fulminant, and the prognosis depends on the timing and adequacy of surgical intervention. Patients who have NSTI usually present with exquisite pain, swelling, and fever, tenderness, erythema, and warm skin, all present in our patient.
Necrotizing Soft Tissue Infection
Two highly unusual features of our patient include the occurrence of NSTI remote from the initial infective source, and involvement of the chest wall. A plausible hypothesis is that the NSTI originated from the paronychia. Our experience and previously published studies suggest that the infection most probably first entered the venous pool of the upper extremities where it initially remained locally dormant, but then disseminated with septic emboli causing the remote lesions (8,9). Recent data from the literature suggest that, similar to this case, clinically “trivial” skin infections such as infected needle puncture or folliculitis can progress into bloodstream infection, with occasional metastatic NSTI (10). No peripheral venipunctures were performed in our patient, ruling out the possibility of iatrogenic bacterial inoculation. A Medline database review revealed only one report of paronychia that caused remote NSTI. Banwell et al. reported a previously fit 55-year-old man whose unsuccessfully treated paronychia led to a necrotizing fasciitis of the chest wall. The patient survived after extensive surgical debridement of the NSTI. Cultures from the wounds grew -hemolytic Streptococcus and coagulasenegative Staphylococcus (11). Our treatment approach was based on recent literature data indicating that mortality from NSTI approaches 100% for those patients not treated with surgery, and that early radical debridement is best supplemented with administration of clindamycin and penicillin for wide antibiotic coverage that includes -hemolytic Streptococcus (12). NSTI is known to affect most frequently the abdominal wall or extremities; involvement of the chest wall is extremely rare, with only 20 reported cases (11,13). Among these 20 cases, 13 patients were male, with ages ranging from 10 weeks to 78 years (13). Thirteen patients were postoperative (65%), and significant predisposing factors including carcinoma were described in 75%. In only 25% of the patients, including Banwell et al.’s case, the infection occurred spontaneously or was preceded by a minor injury or clinically insignificant infected wound (11,13). The diagnosis was initially considered in a minority of the cases; 25% of all patients were managed expectantly, with a mortality rate of 60%. The infection was polymicrobial in 55%, with 25% infected with group A Streptococcus and another 20% with either single microorganisms or negative cultures. Among the survivors, two had secondary healing, five experienced de-
e13
layed skin grafting over the granulating wound, and one had skin grafting combined with muscle transfer (13). The nearly simultaneous occurrence of the paronychia, NSTI, and septic phlebitis, and their identical bacteriology suggest that our patient’s NSTI most probably occurred as a result of metastatic infection. We could find no predisposing illness or anatomic condition that could explain the location of NSTI. Our case and review of the literature suggest that life-threatening NSTI can occur after paronychia. In addition, early diagnosis and aggressive surgical and intensive medical treatments are essential to patient survival. NSTI that occurs after superficial skin infections should be managed in the same way as more severe, deeper tissue infections. REFERENCES 1. Shroff PS, Parikh DA, Fernandez RJ, Wagle UD. Clinical and mycological spectrum of cutaneous candidiasis in Bombay. J Postgrad Med 1990;36:83– 6. 2. Alam M, Scher RK. Indinavir-related recurrent paronychia and ingrown toenails. Cutis 1999;64:277– 8. 3. Tosti A, Piraccini BM, D’Antuono A, Marzaduri S, Bettoli V. Paronychia associated with antiretroviral therapy. Br J Dermatol 1999;140:1165– 8. 4. Weinzweig N, Gonzalez M. Surgical infections of the hand and upper extremity: a county hospital experience. Ann Plast Surg 2002;49:621–7. 5. Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113– 6. 6. Journeau P. Hand infections in children [French]. Arch Pediatr 2000;7:779 – 83. 7. World Health Organization. Necrotizing fasciitis, United Kingdom. Wkly Epidemiol Rec 1994;69:165– 6. 8. Hidalgo-Carballal A, Suarez-Mier MP. Sudden unexpected death in a child with varicella caused by necrotizing fasciitis and streptococcal toxic shock syndrome. Am J Forensic Med Pathol 2006; 27:93– 6. 9. Sanyal AJ, Reddy KR. Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998;115:110 –5. 10. Regev A, Weinberger M, Fishman M, Samra Z, Pitlik SD. Necrotizing fasciitis caused by Staphylococcus aureus. Eur J Clin Microbiol Infect Dis 1998;17:101–3. 11. Banwell PE, Pereira J, Powell BW. Symmetrical necrotizing chest wall infection following paronychia. J Accid Emerg Med 1998;15: 58 – 66. 12. Kaul R, McGeer A, Low DE, Green K, Schwartz B. Populationbased surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med 1997;103:18 –24. 13. Losanoff JE, Richman BW, Jones JW. Necrotizing soft tissue infection of the chest wall. J Cardiovasc Surg (Torino) 2002;43: 549 –52.
doi:10.1016/j.jemermed.2007.11.008
Clinical Communications: Adults
CAN PARONYCHIA CAUSE A REMOTE NECROTIZING SOFT TISSUE INFECTION? Julian E. Losanoff,
MD,*
Anne E. Missavage,
MD,†
Paul Linneman,
RN,‡
and Boyd E. Terry,
MD‡
*Department of Surgery, Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, †Department of Surgery, Michigan State University, Lansing, Michigan, and ‡Department of Surgery, University of Missouri-Columbia, Columbia, Missouri Reprint Address: Julian E. Losanoff, MD, John D. Dingell VAMC (11S), 4646 John R. Street, Suite 400, Detroit, MI 48201
e Abstract—Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome. © 2011 Elsevier Inc.
extremity. Cultures reveal predominantly Gram-positive aerobes (62%), including Streptococci, in 29.5% of the patients (4). Treatment options for paronychia include warm-water soaks, oral antibiotic therapy, and surgical drainage (5). Untreated paronychia can lead to significant morbidity, especially in immunocompromised patients. Involvement of the adjacent tendons, joints, bone, and soft tissues is rarely seen; treatment requires an individualized approach that is guided by both the extent of infection and underlying condition (4 – 6). We present our recent experience with necrotizing soft tissue infection (NSTI) of the chest wall, abdominal wall, and thigh, probably resulting from paronychia in a previously healthy patient.
e Keywords—paronychia; chest wall; abdominal wall; extremities; necrotizing fasciitis; necrotizing infection; complications; surgery
INTRODUCTION
CASE REPORT
Paronychia affects the soft tissue folds surrounding the nail and is considered one of the most common infections of the extremities. Predisposing factors include overzealous manicuring, nailbiting, diabetes mellitus, and occupations in which the hands are frequently immersed in water. Paronychias also have been reported in association with a variety of medications, including antiretroviral therapy for human immunodeficiency virus infection (1–3). A recent trial found that the condition affects 1% of the patients who present to the Emergency Department with surgical infection of the hand and upper
A 39-year-old previously healthy woman presented to the Emergency Department with a vesicular rash affecting the right chest and flank and the left thigh, increasing pain, pyrexia, and general malaise. The patient’s past medical history was significant for an episode of paronychia affecting multiple fingers that was treated by her family physician. The diagnosis had been confirmed by a consulting dermatologist. Culture from the lesions grew Streptococcus pyogenes susceptible to the prescribed local and systemic antibiotics. The paronychia completely resolved in less than 2 weeks, however, a simul-
RECEIVED: 19 December 2005; FINAL ACCEPTED: 22 May 2007
SUBMISSION RECEIVED:
20 March 2007;
e11
e12
taneous vesicular rash involved the right chest and flank and the left thigh. The patient’s condition worsened rapidly. None of the patient’s family had a history of sore throat. The vital signs included surface temperature of 39°C, blood pressure 90/50 mm Hg, pulse 140 beats/min, and respirations 28 breaths/min. Examination of the respiratory system revealed a normal oropharynx and coarse breath sounds bilaterally. The abdomen was unremarkable. Laboratory studies were significant for a leukopenia of 1400/mm3 and coagulopathy (international normalized ratio 2.8 and a platelet count of 42,000 per microliter). Human immunodeficiency virus testing was negative. The affected areas measured approximately 2 ⫻ 2 cm each and were warm, markedly edematous, and extremely tender. Necrotizing soft tissue infection was suspected. An Infectious Disease consultation was obtained. A left subclavian central line was placed through which parenteral fluids, imipenem, clindamycin, and high doses of penicillin were started. No peripheral lines were used. Necrotizing soft tissue infection was suspected, and the patient was brought to the operating room. Exploration of the affected areas revealed foulsmelling brownish exudate and necrosis of the fat, fascia, and superficial muscles extending beyond the operative area. The affected skin was excised. The necrotic fat, fascia, and muscles were thoroughly debrided and excised until healthy, bleeding tissue with normal color surrounded the surgical margins. The wounds (Figures 1, 2) were packed and the patient was transferred to the intensive care unit, where she required ventilatory and enteral nutritional support. Culture from the excised tissue specimens grew S. pyogenes susceptible to the prescribed antibiotics. Histology from the operative specimens was
J. E. Losanoff et al.
Figure 2. Necrotizing infection of the left thigh.
consistent with streptococcal necrotizing soft tissue infection affecting all tissue layers. Over the next 10 days, intensive bedside wound care with pulse irrigation and debridements were performed to remove more necrotic fat and fascia. The remaining muscles remained intact. Despite the successful wound care, the patient continued to have persistent spiking fevers. Physical examination revealed multiple deep tender areas along both the cephalic veins. A clinical diagnosis of septic thrombophlebitis was made and excision of the veins performed, with rapid resolution of the fever. Cultures from the veins grew S. pyogenes. Histology showed severe neutrophilic leukocyte infiltration of the veins, with abscesses in thrombi consistent with streptococcal phlebitis. Four weeks after admission to the hospital, the chest and flank wounds were successfully treated with split thickness skin grafts. All other wounds were closed primarily. The patient was last seen 3 months after discharge from the hospital. She was free of infection, and had no functional deficit in the areas of NSTI. DISCUSSION
Figure 1. Postoperative photograph demonstrating the extent of necrotizing infection in the chest and right flank.
NSTI is a rare, rapidly progressive infectious process primarily involving the fascia and the subcutaneous tissue. Angiothrombotic microbial invasion of the microcirculation and liquefactive necrosis rapidly progress and destroy the tissue planes. It is a life-threatening infection that is uncommon, with approximately 500 –1500 cases reported in the United States annually (7). The progression of the disease is typically fulminant, and the prognosis depends on the timing and adequacy of surgical intervention. Patients who have NSTI usually present with exquisite pain, swelling, and fever, tenderness, erythema, and warm skin, all present in our patient.
Necrotizing Soft Tissue Infection
Two highly unusual features of our patient include the occurrence of NSTI remote from the initial infective source, and involvement of the chest wall. A plausible hypothesis is that the NSTI originated from the paronychia. Our experience and previously published studies suggest that the infection most probably first entered the venous pool of the upper extremities where it initially remained locally dormant, but then disseminated with septic emboli causing the remote lesions (8,9). Recent data from the literature suggest that, similar to this case, clinically “trivial” skin infections such as infected needle puncture or folliculitis can progress into bloodstream infection, with occasional metastatic NSTI (10). No peripheral venipunctures were performed in our patient, ruling out the possibility of iatrogenic bacterial inoculation. A Medline database review revealed only one report of paronychia that caused remote NSTI. Banwell et al. reported a previously fit 55-year-old man whose unsuccessfully treated paronychia led to a necrotizing fasciitis of the chest wall. The patient survived after extensive surgical debridement of the NSTI. Cultures from the wounds grew -hemolytic Streptococcus and coagulasenegative Staphylococcus (11). Our treatment approach was based on recent literature data indicating that mortality from NSTI approaches 100% for those patients not treated with surgery, and that early radical debridement is best supplemented with administration of clindamycin and penicillin for wide antibiotic coverage that includes -hemolytic Streptococcus (12). NSTI is known to affect most frequently the abdominal wall or extremities; involvement of the chest wall is extremely rare, with only 20 reported cases (11,13). Among these 20 cases, 13 patients were male, with ages ranging from 10 weeks to 78 years (13). Thirteen patients were postoperative (65%), and significant predisposing factors including carcinoma were described in 75%. In only 25% of the patients, including Banwell et al.’s case, the infection occurred spontaneously or was preceded by a minor injury or clinically insignificant infected wound (11,13). The diagnosis was initially considered in a minority of the cases; 25% of all patients were managed expectantly, with a mortality rate of 60%. The infection was polymicrobial in 55%, with 25% infected with group A Streptococcus and another 20% with either single microorganisms or negative cultures. Among the survivors, two had secondary healing, five experienced de-
e13
layed skin grafting over the granulating wound, and one had skin grafting combined with muscle transfer (13). The nearly simultaneous occurrence of the paronychia, NSTI, and septic phlebitis, and their identical bacteriology suggest that our patient’s NSTI most probably occurred as a result of metastatic infection. We could find no predisposing illness or anatomic condition that could explain the location of NSTI. Our case and review of the literature suggest that life-threatening NSTI can occur after paronychia. In addition, early diagnosis and aggressive surgical and intensive medical treatments are essential to patient survival. NSTI that occurs after superficial skin infections should be managed in the same way as more severe, deeper tissue infections. REFERENCES 1. Shroff PS, Parikh DA, Fernandez RJ, Wagle UD. Clinical and mycological spectrum of cutaneous candidiasis in Bombay. J Postgrad Med 1990;36:83– 6. 2. Alam M, Scher RK. Indinavir-related recurrent paronychia and ingrown toenails. Cutis 1999;64:277– 8. 3. Tosti A, Piraccini BM, D’Antuono A, Marzaduri S, Bettoli V. Paronychia associated with antiretroviral therapy. Br J Dermatol 1999;140:1165– 8. 4. Weinzweig N, Gonzalez M. Surgical infections of the hand and upper extremity: a county hospital experience. Ann Plast Surg 2002;49:621–7. 5. Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113– 6. 6. Journeau P. Hand infections in children [French]. Arch Pediatr 2000;7:779 – 83. 7. World Health Organization. Necrotizing fasciitis, United Kingdom. Wkly Epidemiol Rec 1994;69:165– 6. 8. Hidalgo-Carballal A, Suarez-Mier MP. Sudden unexpected death in a child with varicella caused by necrotizing fasciitis and streptococcal toxic shock syndrome. Am J Forensic Med Pathol 2006; 27:93– 6. 9. Sanyal AJ, Reddy KR. Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998;115:110 –5. 10. Regev A, Weinberger M, Fishman M, Samra Z, Pitlik SD. Necrotizing fasciitis caused by Staphylococcus aureus. Eur J Clin Microbiol Infect Dis 1998;17:101–3. 11. Banwell PE, Pereira J, Powell BW. Symmetrical necrotizing chest wall infection following paronychia. J Accid Emerg Med 1998;15: 58 – 66. 12. Kaul R, McGeer A, Low DE, Green K, Schwartz B. Populationbased surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med 1997;103:18 –24. 13. Losanoff JE, Richman BW, Jones JW. Necrotizing soft tissue infection of the chest wall. J Cardiovasc Surg (Torino) 2002;43: 549 –52.