Devastating scalp infections

Brief Reports

Devastating Scalp Infections MARK S. GRANICK, MD, WILLIAM CONKLIN, MD, SAI RAMASASTRY, MD, THOMAS S. TALAMO, MD* The treatment of scalp wounds is occasionally complicated by infection. Although infected scalp wounds are generally limited ‘and readily treated, they can progress to devastating proportions if not promptly and aggressively managed. This report highlights three such cases of severe infection: extensive subgaleal abscess, fatal necrotizing fasciitis, and widespread carbunculosis. The authors emphasize the need for proper assessment of scalp wounds, meticulous cleansing and closure of all fresh wounds, definitive drainage of newly infected wounds, and adherence to sound surgical principles in managing these wounds. (Am J Emerg Med 1988;4:136-140)

Scalp infections, which occasionally complicate the management of scalp wounds, can be devastating. Acute management of scalp wounds requires adherence to meticulous surgical technique. Lack of prompt and aggressive management of infected scalp wounds can lead to severe morbidity and even mortality. The following cases illustrate three manifestations of rampant infection of the scalp following inadequate treatment of wounds. CASE REPORTS Case 1: Subgaleal

Abscess

A 2%year-old white man suffered an l&cm laceration of the left forehead and scalp five days before admission, while River. The wound was reswimming in the Monongahela

Physical examination revealed a mildly febrile man with erythema. warmth, and tenderness over the left frontal and temporoparietal regions. The left eyelid was edematous with marked conjunctival injection. Fluctuance was present over the forehead and scalp, and foul-smelling, sanguino-purulent drainage from the posterior aspect of the sutured wound was observed. Laboratory studies revealed a white blood cell count of 11,800 with a left shift. Skull radiographs were not remarkable for any bony abnormalities. Cultures of the initial drainage grew Klebsiella. Escherichia coli, Morganella morgagni. Enterobacter, Serratia, and Clostridia perfringens. In the emergency department, the posterior third of the scalp wound was opened, and foul-smelling pus was evacuated. The galea appeared necrotic, and there was one area of exposed calvarium. The wound was copiously irrigated with saline-povidone-iodine solution. Irrigation catheters were inserted, and triple antibiotic (penicillin, gentamicin, cefazolin) therapy was instituted. Because of lack of improvement, the entire wound was debrided of grossly necrotic tissue and drained (Fig. 1). The wound was then packed with gentamicin-impregnated gauze. Culture sensitivities prompted a change in antibiotics to cefotaxime and penicillin. The wound improved and edema subsided following additional debridement over the next 12 days, and the patient underwent delayed primary closure. The wound healed without further compiication. Treatment of this infection necessitated 22 days of in-hospital stay and 20 days of intravenous antibiotic therapy.

paired at an outlying hospital, and he was placed on a regimen of broad-spectrum antibiotics with tetanus prophylaxis.

The wound developed serosanguinous drainage associated with progressive swelling of the left temporoparietal area. This was initially thought to be a hematoma, and no further therapy was initiated. The patient presented to our unit three days later with progressive scalp pain and increasing erythema and edema of the left eyelid and forehead. From the Departments of Plastic Surgery and *Pathology, versity of Pittsburgh, Pittsburgh, Pennsylvania. Manuscript received gust 15, 1985.

February

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Address reprint requests to Dr. Granick: Suite 235, Pittsburgh, PA 15224. Key Words: Carbuncle, necrotizing scalp wound(s), subgaleal abscess. 136

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FIGURE 1. Subgaleal abscess. The extensive incision required to adequately drain a widespread subgaleal abscess is shown.

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Case 2: Necrotizing Fasciitis A 93-year-old woman with no prior medical history of diabetes, renal failure, or other significant chronic illnesses, sustained a scalp laceration over the occiput from a fall three days before admission. The laceration was cleaned by the nursing home staff physician but not surgically repaired. During the 12 hours preceeding admission, the wound became erythematous, edematous, and fluctuant. The patient’s mental status began to deteriorate. On arrival at the emergency department, the patient was lethargic and oriented only to self. This emaciated woman had an area of fluctuance 4 cm in diameter under necrotic, thin skin on the central occiput. Surrounding this was a zone of erythema and purplish discoloration involving the entire posterior scalp. She was afebrile. Initial laboratory studies revealed a white blood cell count of 34,000 with a left shift, blood urea nitrogen (BUN) of 75 mgidl, and creatinine of 3.5 mg/dl. Gram stain of the posterior scalp drainage demonstrated gram-positive cocci in clusters. Results of skull radiographs were normal. Within an hour the ecchymosis extended down the nape of the neck (Fig. 2). No subcutaneous emphysema was evident. Intravenous nafcillin (500 mg) was administered at this time. The patient’s breathing precipitously became rapid and labored, and she was intubated. A surgical consultation was then obtained. The diagnosis of necrotizing fasciitis was

.

FIGURE 3. The patient grossly necrotic tissue.

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made, and rapid intravenous re-hydration (normal saline solution at 200 ml per hour) and intensive intravenous antibiotic therapy (cefotaxime, 1 g; penicillin, 2,000,OOO units) were immediately instituted. Radical surgical debridement of all grossly necrotic tissue was then performed in the operating suite. Aerobic and anaerobic cultures of tissue fluid from fresh scalp incisions were obtained. No pus was observed. The skin, subcutaneous tissue, and superficial fascia were grossly necrotic, whereas underlying muscle appeared healthy (Fig. 3). The patient did not recover consciousness following the surgical intervention. She required mechanical ventilation with positive end expiratory pressure. Cultures grew heavy group A beta-hemolytic Streptococcus, heavy coagulase-positive Staphylococcus aureus, and coagulasenegative Staphylococcus epidermidis. Intravenous administration of cefotaxime and penicillin were continued. Frequent dressing changes with bacitracin-impregnated gauze, and further debridements were performed at bedside. The patient continued to deteriorate and died two days later of multiple organ system failure.

Case 3: Carbuncle FIGURE 2. Necrotizing fasciitis. All of the discolored skin surrounding the central core of necrotic occipital scalp is affected by the infection. A wide margin of normal-appearing skin is undermined by necrotic fascia.

A 70-year-old diabetic man developed a pruritic eczematous lesion of the posterior scalp that was initially treated by his family doctor with topical steroid cream. He reportedly continued to traumatize the area by scratching and, over the next two weeks, developed a progressively en137

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FIGURE 4. tizing

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larging painful occipital mass. It was not until this mass began spontaneously draining foul-smelling material that he again sought medical attention. The posterior scalp revealed diffuse erythema and induration measuring 14 cm in diameter. A necrotic, draining wound was located centrally (Fig. 5). In the emergency department, debridement of this necrotic tissue provided improved drainage, and he was placed on intravenous clindamycin, gentamicin, and cefalothin therapy until wound cultures were available. Laboratory studies revealed an elevated white blood cell count of 25,000, with a left shift, and a blood-sugar level of 297 mg/dl. Blood cultures were negative. After 24 hours, there was significant improvement, and he was taken to the operating room for further decompression of the wound. The infection was found to extend through the entire thickness of 138

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dermis and subcutaneous tissue into the subgaleal space. Pus oozed from the cut edges of the wound as well as from beneath the involved galea. After debriding a 6- x &cm zone of necrotic tissue. scalp flaps were raised producing drainage of the subgaleal space. The galea was then extensively scored, resulting in further egress of pus from the subcutaneous tissue in the indurated area. The large wound was copiously irrigated with saline solution and dressed with sponges impregnated with povidone-iodine. Cultures grew aureus sensitive to cefalothin, with out Staphylococcus which he was treated intravenously. Pathological evaluation of the scalp specimen revealed full-thickness necrosis with severe acute and chronic inflammation extending through all tissue layers. After nearly three weeks of intravenous antibiotics (Fig. 6) and frequent local wound care. the infection

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resolved and the wound began to heal. The patient elected to let his wound heal secondarily. The lesion was fully closed within two months (Fig. 7). DISCUSSION The three case histories presented in this report demonstrate an array of severe infections resulting from seemingly innocuous scalp wounds. Patients who appear to be at risk for these complications include: the chronically ill, aged, or debilitated (Case 2); those with diabetes (Case 3); or patients sustaining a large bacterial innoculum at the time of injury (Case 1). Proper initial management of scalp wounds along with frequent assessment of contaminated wounds should help to prevent these devastating scalp infections. The first patient initially presented with a large contaminated wound that was probably insufficiently cleansed and debrided originally before closure. The subsequent undrained hematoma ultimately became infected. The first excision and drainage was again probably inadequate to obtain a surgically clean wound. Recuperation progressed slowly thereafter, despite aggressive local and systemic care. The error

FIGURE 5. Carbunculosis. An extensive scalp carbuncle is shown here before drainage. Pus permeated all layers of tissue from epidermis to galea. and pus was draining from multiple skin pores.

FIGURE 6. The patient in Figure 5 is shown three weeks after excision and drainage.

in management resulted from underassessment of the severity of the infection and inadequate debridement in the initial stages. One should be aware that in scalp infections, pus can easily dissect in the subgaleal plane leading to extensive subgaleal abscess. The second patient developed necrotizing fasciitis, a rapidly progressive, highly destructive bacterial infection of the subcutaneous tissue and fascia. There is a spectrum of disease occurring under the name of “necrotizing fasciitis.” Generally, the infections occur in patients with reduced host-defense mechanisms.1 The patient presented in this report, although elderly, had no history of chronic underlying disease. The lesion rarely affects the head and neck regions.2 The infection begins as a diffuse patch of erythema and progresses over hours or days to widespread undermining and necrosis of skin, usually, but not always, associated with severe toxemia. The necrotic process produced by the bacterial infection begins in the subcutaneous tissues, extends rapidly, usually from the point of trauma, and undermines the viable skin surface. Skeletal muscle is usually not involved. As the infection progresses, vascular thrombosis in subcutaneous tissue and deep dermis leads to dermal necrosis with sloughing and ulceration. The pathology in this case is consistent with this progression of disease. Figure 4 demonstrates bacterial aggregates in the walls of large, thrombosed blood vessels with overlying, still-viable skin. Bacteriological studies in this case confirmed the presence of organisms known to be associated with necrotizing fasciitis.3 The pathogenesis of this clinical entity is still unclear. The characteristic undermining of skin produced by dissecting subcutaneous necrosis may be caused by the production of hemolysins, fibrinolysins, or hyaluronidases by invading bacteria.4 The management of necrotizing fasciitis must in139

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coccus aureus infection of several adjacent hair follicles, associated with an intense local inflammatory response. A carbuncle starts as an exquisitely tender nodule which enlarges over a period of five to seven days, after which pus begins to ooze out of the affected follicles. Central ulceration then develops. Constitutional symptoms are often present. Carbuncles most commonly occur in the scalps of middle aged and older men. There are a variety of predisposing systemic disorders associated with the occurrence of carbuncles, including diabetes mellitus. immune deficiency states, steroid dependency, and others.6.7 Treatment includes the use of systemic antibiotics and aggressive drainage. SUMMARY

FIGURE 7. The patient in Figures 5 and 6 has healed secondarily after two months of local wound care.

elude aggressive treatment of the systemic toxicity as well as local fasciotomy and debridement. Death may ensue from sepsis, cardiac failure, respiratory failure, renal failure, or multi-system failure. Early recognition of the clinical process along with prompt, aggressive, surgical intervention is the most significant factor affecting survival.5 The patient should be treated from the outset with broad-spectrum intravenous antibiotics. Post-operatively, the wounds need frequent dressing changes and inspections. Multiple debridements are usually necessary before all of the local disease is controlled. Hyperbaric oxygen may also play an increasingly important role in the treatment of necrotizing fasciitis. The third patient, the one with diabetes, presented with an extensive dermal and subcutaneous abscess of the posterior scalp that violated the galea. Excision of the grossly necrotic tissue, wound irrigation, and systemic antibiotics were simply insufficient to control this widespread infection. Decompression of the subgaleal space, as well as the subcutaneous tissue, was a crucial step in his treatment. Following definitive surgical intervention, high-dose systemic antibiotics, and vigorous wound care, resolution of the infection was gradual. The most likely diagnosis of this unusual infection is a carbuncle. A carbuncle is an extensive, deeply infiltrating suppurative lesion that occurs in thick, inelastic skin.6,7 The lesion derives from a Staphylo-

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This report highlights three cases of devastating scalp-wound infection. Each case developed from initial underassessment and undertreatment of wounds of various etiologies. Treatment of these infections included systemic antibiotics and aggressive surgical debridement and drainage. Despite such measures, one patient, with necrotizing fasciitis, died. Recognition of these extreme infections as sequelae of common scalp wounds underscores the need for proper assessment, meticulous cleansing, and closure of all fresh wounds with definitive surgical drainage of newly infected wounds. Adherence to sound surgical principles in wound management cannot be stressed too strongly. The authors thank E. Douglas Newton, MD, Dennis J. Hurwitz, MD, and William Swartz, MD, who were instrumental in the clinical management of the patients presented in this report.

REFERENCES 1. Tehrani MA, Ledingham IM. Necrotizing fasciitis. Postgrad Med J 1977;53:237-242. 2. Krespi YP, Lawson W, Blaugrund SM, et al. Massive necrotizing infections of the neck. Head Neck Surg 1981;3: 475-481. Giulaiano A, Lewis F, Hadley K, et al. Bacteriology of necrotizing fasciitis. Am J Surg 1977;134:52-56. Meade JW, Mueller CB. Necrotizing infections of subcutaneous tissue and fascia. Ann Surg 1968;168:274-280. Janevicius RV, Hann SE, Batt MD. Necrotizing fasciitis. Surg Gynecol Obstet 1982;154:97-102. Swartz MN, Weinberg AV. Bacterial diseases with subcutaneous involvement: Infections due to gram-positive bacteria. In Fitzpatrick TB, Eisen AZ, Wolff K, et al (eds). Dermatology in General Medicine. New York: McGrawHill, 1977:1440-1442. 7. Roberts SOB, Rook A. Bacterial Infections. In Rook A, Wilkinson DS, Ebling FJG (eds). Textbook of Dermatology. Oxford: Blackwell Scientific Pub, 1979:554.