- Email: [email protected]
Necrotizing fasciitis caused by group A Streptococcus with no apparent predisposing factors presenting as acute abdomen
International Journal of Infectious Diseases (2008) 12, 332—344
http://intl.elsevierhealth.com/journals/ijid
CORRESPONDENCE Necrotizing fasciitis caused by group A Streptococcus with no apparent predisposing factors presenting as acute abdomen Necrotizing fasciitis of the abdomen is an uncommon, acute surgical emergency that requires a high index of suspicion and immediate intervention with intravenous antibiotics and surgical debridement. Most cases have a predisposing factor, mainly penetrating or blunt trauma. A previously healthy, 27-year-old female was admitted with a 3-day history of progressive, dull aching right lower quadrant (RLQ) abdominal pain, radiating to the umbilical and inguinal regions and down to the right thigh. It initially occurred with ambulation, but later her pain progressed to a non-remitting pain. The patient had nausea, vomiting, malaise, fever, and chills. Her past surgical history was significant for a remote appendectomy, ovarian cystectomy 2 years previously, and bilateral tubal ligation 9 months previously. Physical examination showed the patient in severe pain. She was pale, hypotensive, tachypneic, and tachycardic with a temperature of 39 8C. A chest examination showed bilaterally diminished air entry at both bases. Cardiac examination showed tachycardia. Abdominal examination showed mild erythema of the skin in the RLQ, hypoactive bowel sounds, and marked tenderness to palpation in the RLQ and inguinal area with rigidity and rebound tenderness. Bimanual examination showed a moderate cheesy vaginal discharge, no cervical motion tenderness, and no palpable masses. Rectal examination was unremarkable. The right lower extremity examination showed calf and thigh swelling, with tenderness and erythema, with no crepitus, fluctuance, or purplish discoloration. Laboratory data showed a white blood cell (WBC) count of 14.9 109/l (72% neutrophils, 4% lymphocytes, and 21% band forms), hemoglobin of 90 g/l, hematocrit of 28%, and a platelet count of 126 109/l. Serum sodium was 129 mmol/l, blood urea nitrogen was 20 mg/dl, and creatinine was 1.7 mg/dl. Her hepatic profile showed an aspartate aminotransferase level ranging between 16 and 52 IU/l. The prothrombin time was 16.1 s with an international normalized ratio (INR) of 2.02. The activated partial thromboplastin time was 39.6 s. Testing for serum b-human chorionic gonadotropin was negative. Blood cultures were negative. Her urinalysis showed 5—10 WBC/high-power field (HPF), but no bacteria. Transvaginal ultrasound showed no pathology.
A magnetic resonance imaging (MRI) of the pelvis was done (Figure 1). The patient was diagnosed, based on the MRI findings, with necrotizing fasciitis and muscle necrosis involving the pelvis, retroperitoneum, and upper thigh. This was confirmed at laparotomy and right thigh exploration. The muscles involved were the sartorius, psoas, external oblique, internal oblique, transversus abdominis, rectus abdominis, and quadriceps femoris. No intra-abdominal or intrapelvic visceral involvement was seen. She was treated with intravenous piperacillin/tazobactam, vancomycin, and clindamycin with extensive tissue debridement, including the muscles and fascia involved. Myoflaps were used. A repeat surgical debridement was done at 2 and 3 weeks and the abdominal wound was allowed to heal using vacuum assisted closure. Tissue culture grew group A Streptococcus. The absence of conjunctivitis, strawberry tongue, typical rash, and the finding of negative blood cultures made a diagnosis of toxic shock syndrome unlikely, although the patient had some criteria of toxic shock syndrome such as renal failure, hypotension, vomiting, diarrhea, and rapid onset fever. Despite this, the patient was given fresh frozen plasma. Intravenous g-globulin was not administered. During her hospital course, the patient underwent an extensive rehabilitation program. Necrotizing fasciitis is an acute surgical emergency requiring both a high index of suspicion for diagnosis and prompt operative intervention.1 To the best of our knowledge, this case is among the first few cases to describe such an extensive necrosis of muscle and fascia in a patient with no apparent predisposing factors.2 Predisposing factors for necrotizing fasciitis include, but are not limited to: history of trauma, surgical interventions such as liposuction,3 displaced gastrostomy tubes,4 perforated diverticular disease,5 fistulizing Crohn’s disease,6 colon cancer perforation, diabetes mellitus,1 Amyand’s hernia,7 empyema,8 insecticide injection,9 varicella infection,10 following cesarean section,11 in AIDS patients,12 acute appendicitis,13 and following gallbladder perforation and laparoscopic cholecystectomy.14,15 In children, omphalitis and necrotizing enterocolitis are predisposing factors.16,17 In our case, initial diagnosis was delayed because of the inflammatory process in the lower extremity, absence of significant skin erythema, and tissue crepitus, and this is a major point to learn from, which is that any pelvic pathology can extend to the lower extremity through the obturator foramen and make the presentation of an acute abdomen
1201-9712/$32.00 # 2007 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
333
Correspondence
7.
8.
9.
10.
11. 12. 13.
Figure 1 MRI of the pelvis showing pelvic fascial fluid and edema with a hyperintense signal of the fascia surrounding the muscles in the pelvis, suggestive of myofasciitis.
14.
15.
hard to initially evaluate and treat. Necrotizing fasciitis should be considered in the differential diagnosis of severe abdominal pain. Conflict of interest: No conflict of interest to declare.
References 1. Huljev D. Necrotizing fasciitis of the abdominal wall with lethal outcome: a case report. Hernia 2007;11:271—8. 2. Marron CD, McArdle GT, Rao M, Sinclair S, Moorehead J. Perforated carcinoma of the cecum presenting as necrotizing fasciitis of the abdominal wall, the key to early diagnosis and management. BMC Surgery 2006;6:11. 3. Sharma D, Dalencourt G, Bitterly T, Benotti PN. Small intestinal perforation and necrotizing fasciitis after abdominal liposuction. Aesthetic Plast Surg 2006;30:712—6. 4. MacLean AA, Miller G, Bamboat ZM, Hiotis K. Abdominal wall necrotizing fasciitis from dislodged percutaneous endoscopic gastrostomy tubes: a case series. Am Surg 2004;70:827—31. 5. Alvarez-Zepeda C, Hermansen-Truan C, Valencia-Lazo O, AzolasMarcos R, Gatica-Jimenez F, Castillo-Avendano J. Necrotizing fasciitis of the abdominal wall secondary to a perforated sigmoid diverticulum in a Spiegel’s hernia. A case report. Cir Cir 2005;73:133—6. 6. Masaki F, Gozo N, Yuuichi H, Hirosi I, Osamu M, Tsuneyuki Y. Necrotizing fasciitis secondary to intraabdominal infec-
Septicemia caused by Corynebacterium macginleyi: a rare form of extraocular infection Non-diphtheria Corynebacterium species have emerged as nosocomial pathogens and cause diseases in risk populations, such as the immunocompromised and patients with indwelling medical devices.1 Recognized cases of bacteremia with non-diphtheria Corynebacterium spp have become more prevalent.1 We report herein the first case of Corynebacterium
16.
17.
tion in Crohn’s disease. J Clin Gastroenterol 2005;39: 448—9. Marron CD, Khadim M, McKay D, Mackle EJ, Peyton JW. Amyand’s hernia causing necrotizing fasciitis of the anterior abdominal wall. Hernia 2005;9:381—3. Praba-Egge AD, Lanning D, Broderick TJ, Yelon JA. Necrotizing fasciitis of the chest and abdominal wall arising from an empyema. J Trauma 2004;56:1356—61. Terzi C, Bacakoglu A, Unek T, Ozkan MH. Chemical necrotizing fasciitis due to household insecticide injection: is immediate radical surgical debridement necessary? Hum Exp Toxicol 2002;21:687—90. Billiemaz K, Lavocat MP, Teyssier G, Chavrier Y, Allard D, Varlet F. Varicella complicated with necrotizing fasciitis caused by group A hemolytic Streptococcus. Arch Pediatr 2002;9:262—5. Krowlikowski A, Gowri V, Radha K. Necrotizing fasciitis of abdominal wall after cesarean section. Saudi Med J 2000;21:399—400. Roy PK, Patel SC, Kataria YP. Necrotizing fasciitis of abdominal wall in AIDS. Dig Dis Sci 2001;46:1139—42. Fujiwara H, Nomura H, Yasuda K, Kuroda D, Kato M, Ohyanagi H. Acute appendicitis complicated with necrotizing soft tissue infections in the elderly: report of a case. Hepatogastroenterology 1999;46:1702—5. Rehman A, Walker M, Kubba H, Jayatunga AP. Necrotizing fasciitis following gallbladder perforation. J R Coll Surg Edinb 1998;43:357. Jansen M, Schippers E, Schumpelick V. Necrotizing fasciitis after laparoscopic cholecystectomy. Chirurg 1998;69:667—8. Ulloa-Gutierrez R, Rodriguez-Calzada H, Quesada L, Arguello A, Avilla-Aguero ML. Is it acute omphalitis or necrotizing fasciitis? Report of three fatal cases. Pediatr Emerg Care 2005;21:600—2. Ignacio RC, Falcone Jr RA, Warner BW. Necrotizing fasciitis: a rare complication of neonatal necrotizing enterocolitis. J Pediatr Surg 2005;40:1805—7.
Hamed A. Shabaneh Al-Tamimi* Lee Thomas Department of Internal Medicine, Division of Gastroenterology, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, Texas 79430, USA *Corresponding author. Tel.: +1 806 743 3155; fax: +1 806 743 3148 E-mail address: [email protected] (H.A.S. Al-Tamimi) Corresponding Editor: James Muller, Pietermaritzburg, South Africa 29 May 2007 doi:10.1016/j.ijid.2007.08.004
macginleyi septicemia in an immunocompromised adult patient, which resulted in death. A 73-year old male was hospitalized with headaches, disorientation, instability, and vomiting. The patient had previously been diagnosed with non-Hodgkin lymphoma, hypertension, and type 2 diabetes mellitus. Physical examination showed partial disorientation and globally diminished osteomuscular reflexes. The patient had no motor or sensory deficits and had no signs of meningococcal irritation.
http://intl.elsevierhealth.com/journals/ijid
CORRESPONDENCE Necrotizing fasciitis caused by group A Streptococcus with no apparent predisposing factors presenting as acute abdomen Necrotizing fasciitis of the abdomen is an uncommon, acute surgical emergency that requires a high index of suspicion and immediate intervention with intravenous antibiotics and surgical debridement. Most cases have a predisposing factor, mainly penetrating or blunt trauma. A previously healthy, 27-year-old female was admitted with a 3-day history of progressive, dull aching right lower quadrant (RLQ) abdominal pain, radiating to the umbilical and inguinal regions and down to the right thigh. It initially occurred with ambulation, but later her pain progressed to a non-remitting pain. The patient had nausea, vomiting, malaise, fever, and chills. Her past surgical history was significant for a remote appendectomy, ovarian cystectomy 2 years previously, and bilateral tubal ligation 9 months previously. Physical examination showed the patient in severe pain. She was pale, hypotensive, tachypneic, and tachycardic with a temperature of 39 8C. A chest examination showed bilaterally diminished air entry at both bases. Cardiac examination showed tachycardia. Abdominal examination showed mild erythema of the skin in the RLQ, hypoactive bowel sounds, and marked tenderness to palpation in the RLQ and inguinal area with rigidity and rebound tenderness. Bimanual examination showed a moderate cheesy vaginal discharge, no cervical motion tenderness, and no palpable masses. Rectal examination was unremarkable. The right lower extremity examination showed calf and thigh swelling, with tenderness and erythema, with no crepitus, fluctuance, or purplish discoloration. Laboratory data showed a white blood cell (WBC) count of 14.9 109/l (72% neutrophils, 4% lymphocytes, and 21% band forms), hemoglobin of 90 g/l, hematocrit of 28%, and a platelet count of 126 109/l. Serum sodium was 129 mmol/l, blood urea nitrogen was 20 mg/dl, and creatinine was 1.7 mg/dl. Her hepatic profile showed an aspartate aminotransferase level ranging between 16 and 52 IU/l. The prothrombin time was 16.1 s with an international normalized ratio (INR) of 2.02. The activated partial thromboplastin time was 39.6 s. Testing for serum b-human chorionic gonadotropin was negative. Blood cultures were negative. Her urinalysis showed 5—10 WBC/high-power field (HPF), but no bacteria. Transvaginal ultrasound showed no pathology.
A magnetic resonance imaging (MRI) of the pelvis was done (Figure 1). The patient was diagnosed, based on the MRI findings, with necrotizing fasciitis and muscle necrosis involving the pelvis, retroperitoneum, and upper thigh. This was confirmed at laparotomy and right thigh exploration. The muscles involved were the sartorius, psoas, external oblique, internal oblique, transversus abdominis, rectus abdominis, and quadriceps femoris. No intra-abdominal or intrapelvic visceral involvement was seen. She was treated with intravenous piperacillin/tazobactam, vancomycin, and clindamycin with extensive tissue debridement, including the muscles and fascia involved. Myoflaps were used. A repeat surgical debridement was done at 2 and 3 weeks and the abdominal wound was allowed to heal using vacuum assisted closure. Tissue culture grew group A Streptococcus. The absence of conjunctivitis, strawberry tongue, typical rash, and the finding of negative blood cultures made a diagnosis of toxic shock syndrome unlikely, although the patient had some criteria of toxic shock syndrome such as renal failure, hypotension, vomiting, diarrhea, and rapid onset fever. Despite this, the patient was given fresh frozen plasma. Intravenous g-globulin was not administered. During her hospital course, the patient underwent an extensive rehabilitation program. Necrotizing fasciitis is an acute surgical emergency requiring both a high index of suspicion for diagnosis and prompt operative intervention.1 To the best of our knowledge, this case is among the first few cases to describe such an extensive necrosis of muscle and fascia in a patient with no apparent predisposing factors.2 Predisposing factors for necrotizing fasciitis include, but are not limited to: history of trauma, surgical interventions such as liposuction,3 displaced gastrostomy tubes,4 perforated diverticular disease,5 fistulizing Crohn’s disease,6 colon cancer perforation, diabetes mellitus,1 Amyand’s hernia,7 empyema,8 insecticide injection,9 varicella infection,10 following cesarean section,11 in AIDS patients,12 acute appendicitis,13 and following gallbladder perforation and laparoscopic cholecystectomy.14,15 In children, omphalitis and necrotizing enterocolitis are predisposing factors.16,17 In our case, initial diagnosis was delayed because of the inflammatory process in the lower extremity, absence of significant skin erythema, and tissue crepitus, and this is a major point to learn from, which is that any pelvic pathology can extend to the lower extremity through the obturator foramen and make the presentation of an acute abdomen
1201-9712/$32.00 # 2007 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
333
Correspondence
7.
8.
9.
10.
11. 12. 13.
Figure 1 MRI of the pelvis showing pelvic fascial fluid and edema with a hyperintense signal of the fascia surrounding the muscles in the pelvis, suggestive of myofasciitis.
14.
15.
hard to initially evaluate and treat. Necrotizing fasciitis should be considered in the differential diagnosis of severe abdominal pain. Conflict of interest: No conflict of interest to declare.
References 1. Huljev D. Necrotizing fasciitis of the abdominal wall with lethal outcome: a case report. Hernia 2007;11:271—8. 2. Marron CD, McArdle GT, Rao M, Sinclair S, Moorehead J. Perforated carcinoma of the cecum presenting as necrotizing fasciitis of the abdominal wall, the key to early diagnosis and management. BMC Surgery 2006;6:11. 3. Sharma D, Dalencourt G, Bitterly T, Benotti PN. Small intestinal perforation and necrotizing fasciitis after abdominal liposuction. Aesthetic Plast Surg 2006;30:712—6. 4. MacLean AA, Miller G, Bamboat ZM, Hiotis K. Abdominal wall necrotizing fasciitis from dislodged percutaneous endoscopic gastrostomy tubes: a case series. Am Surg 2004;70:827—31. 5. Alvarez-Zepeda C, Hermansen-Truan C, Valencia-Lazo O, AzolasMarcos R, Gatica-Jimenez F, Castillo-Avendano J. Necrotizing fasciitis of the abdominal wall secondary to a perforated sigmoid diverticulum in a Spiegel’s hernia. A case report. Cir Cir 2005;73:133—6. 6. Masaki F, Gozo N, Yuuichi H, Hirosi I, Osamu M, Tsuneyuki Y. Necrotizing fasciitis secondary to intraabdominal infec-
Septicemia caused by Corynebacterium macginleyi: a rare form of extraocular infection Non-diphtheria Corynebacterium species have emerged as nosocomial pathogens and cause diseases in risk populations, such as the immunocompromised and patients with indwelling medical devices.1 Recognized cases of bacteremia with non-diphtheria Corynebacterium spp have become more prevalent.1 We report herein the first case of Corynebacterium
16.
17.
tion in Crohn’s disease. J Clin Gastroenterol 2005;39: 448—9. Marron CD, Khadim M, McKay D, Mackle EJ, Peyton JW. Amyand’s hernia causing necrotizing fasciitis of the anterior abdominal wall. Hernia 2005;9:381—3. Praba-Egge AD, Lanning D, Broderick TJ, Yelon JA. Necrotizing fasciitis of the chest and abdominal wall arising from an empyema. J Trauma 2004;56:1356—61. Terzi C, Bacakoglu A, Unek T, Ozkan MH. Chemical necrotizing fasciitis due to household insecticide injection: is immediate radical surgical debridement necessary? Hum Exp Toxicol 2002;21:687—90. Billiemaz K, Lavocat MP, Teyssier G, Chavrier Y, Allard D, Varlet F. Varicella complicated with necrotizing fasciitis caused by group A hemolytic Streptococcus. Arch Pediatr 2002;9:262—5. Krowlikowski A, Gowri V, Radha K. Necrotizing fasciitis of abdominal wall after cesarean section. Saudi Med J 2000;21:399—400. Roy PK, Patel SC, Kataria YP. Necrotizing fasciitis of abdominal wall in AIDS. Dig Dis Sci 2001;46:1139—42. Fujiwara H, Nomura H, Yasuda K, Kuroda D, Kato M, Ohyanagi H. Acute appendicitis complicated with necrotizing soft tissue infections in the elderly: report of a case. Hepatogastroenterology 1999;46:1702—5. Rehman A, Walker M, Kubba H, Jayatunga AP. Necrotizing fasciitis following gallbladder perforation. J R Coll Surg Edinb 1998;43:357. Jansen M, Schippers E, Schumpelick V. Necrotizing fasciitis after laparoscopic cholecystectomy. Chirurg 1998;69:667—8. Ulloa-Gutierrez R, Rodriguez-Calzada H, Quesada L, Arguello A, Avilla-Aguero ML. Is it acute omphalitis or necrotizing fasciitis? Report of three fatal cases. Pediatr Emerg Care 2005;21:600—2. Ignacio RC, Falcone Jr RA, Warner BW. Necrotizing fasciitis: a rare complication of neonatal necrotizing enterocolitis. J Pediatr Surg 2005;40:1805—7.
Hamed A. Shabaneh Al-Tamimi* Lee Thomas Department of Internal Medicine, Division of Gastroenterology, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, Texas 79430, USA *Corresponding author. Tel.: +1 806 743 3155; fax: +1 806 743 3148 E-mail address: [email protected] (H.A.S. Al-Tamimi) Corresponding Editor: James Muller, Pietermaritzburg, South Africa 29 May 2007 doi:10.1016/j.ijid.2007.08.004
macginleyi septicemia in an immunocompromised adult patient, which resulted in death. A 73-year old male was hospitalized with headaches, disorientation, instability, and vomiting. The patient had previously been diagnosed with non-Hodgkin lymphoma, hypertension, and type 2 diabetes mellitus. Physical examination showed partial disorientation and globally diminished osteomuscular reflexes. The patient had no motor or sensory deficits and had no signs of meningococcal irritation.