- Email: [email protected]
Necrotizing Fasciitis in Patients Who Underwent Renal Transplantation
Necrotizing Fasciitis in Patients Who Underwent Renal Transplantation S.-F. Tsai ABSTRACT A 48-year-old man receiving renal transplantation was admitted due to bacterial pneumonia. Unfortunately, he developed septic shock due to Escherichia coli-related necrotizing fasciitis (NF). To date, there have only been 11 such cases reported in the literature and this is the first case caused by E coli. An analysis of all 12 cases showed 83% of patients had the infection in the extremities, 27.3% of pathogens was Streptococcus pyogenes, 50% of patients had shock, but the mortality rate (16.7%) was no greater than that seen in nonerenal transplant patients with NF. The elderly had higher mortality (P ¼ .085) and patients taking mycophenoic acid had a higher risk of death (P ¼ .039).
N
ECROTIZING FASCIITIS (NF) is a devastating infectious disease in the general population. To date, it has rarely been reported in patients receiving renal transplantation (RTX), and to our knowledge, only 11 cases have been previously reported in the literature.1e11 The most common pathogen in RTX patients with NF is Streptococcus pyogenes, and outcome is considered very poor. However, due to the rarity of NF in RTX patients, the pathogens involved, risk factors for mortality, and outcomes are poorly understood. Herein, we report the first case of Escherichia colierelated necrotizing fasciitis. We also summarize all 12 cases and analyze (Mann-Whitney U test for continuous variables or chi-square test for categorical variables) the characteristics and risk factors of NF in RTX patients. This is the first reported case of E colierelated NF and the first study to present a statistical analysis of factors affecting NF in RTX patients. CASE REPORT A 48-year-old man received RTX due to reflux nephropathy-related end-stage renal disease 16 years before this admission. Renal function was 3.0 mg/dL of serum creatinine and the maintenance immunosuppressants were prednisolone (10 mg), tacrolimus (2 mg/ 12 h), and mycophenolic acid (180 mg; 4 tablets, twice daily). He also had new-onset diabetes mellitus (DM) and hypertension. Before this course of admission, he was admitted due to fever and dyspnea for one week. He was diagnosed with bacterial pneumonia based on alveolar patch on chest X-ray (CXR) and yellowish sputum. Pneumonia was much improved after 10 days of treatment with moxifloxacin, but sudden onset of tarry stool occurred, with an estimated volume of 500 g. The patient experienced syncope and fell in the bathroom. Systolic blood pressure dropped from 140 mm Hg to 80 mm Hg and heart rate increased to 140 beats per minute.
Hemoglobin dropped from 11.2 g/dL to 4.4 g/dL at the same time. Initial fluid resuscitation followed by blood transfusion were prescribed to stabilize his vital signs. Due to pulmonary edema and unclear consciousness, an endotracheal tube was inserted, and then gastroduodenoscopy was performed 4 times to stop the bleeding. The lowest hemoglobin level was 3.1 g/dL. During the final gastroduodenoscopy, an active duodenal ulcer with spurting bleeding was detected and 4 metal hemoclips were applied. Once hemoglobin and vital signs were stable, we encouraged diuresis and attempted to wean the patient off the ventilator 7 days after severe hypovolemic shock. Unfortunately, fever occurred and shock recurred. White blood cell (WBC) dropped to 2200/mm3 and thrombocytopenia was also detected (26,000/mm3). Piperacillin/tazobactam was given with fluid resuscitation. Septic workup showed pyuria (35 WBC per high-power field in urine) and clear CXR. Two hours later, skin rash was found over the patient’s right leg. There was no crepitus, ulcer, or bullae. Four hours later, the rash ascended to the right thigh and left flank (Fig 1A). Twenty hours after fever, bullae were found over left leg (Fig 1C). Fluid was not turbid and bullae had a clear base. Computed tomography was used to confirm the diagnosis of NF, which showed asymmetric fascial thickening, and fat stranding. We didn’t see gas tracking along fascial planes or any abscesses formation. Finally, 24 hours after fever, minifasciotomy was performed at bedside and dishwater-like fluid was noticed seeping from the wound (Fig 1C). NF was confirmed finally after this minifasciotomy with
From the Department of Medicine, Division of Nephrology, Taichung Veterans General Hospital and Department of Life Science, Tunghai University, Taichung, Taiwan. Address reprint requests to Shang-Feng Tsai, MD, Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, No. 160, Section 3, Chung-Kang Road, Taichung 407, Taiwan. E-mail: [email protected]
ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.02.142
Transplantation Proceedings, 45, 2807e2810 (2013)
2807
2808
TSAI
Fig 1. Skin rash, ballae, and necrotizing fasciitis. (A) Rash over whole left lower limb. (B) Necrosis tissue over fascia of muscle. (C) Bullae over left high.
dishwater-like water. Fasciotomy was performed 30 hours after this septic shock. Piperacillin/tazobactam was shifted to ertapenem and wet dressings were applied for a total of 2 months. The blood culture, urine culture, and fluid culture from NF were all E coli. He suffered from bacterial pneumonia, hypovolemic shock, and NF-related septic shock, but he was eventually saved and the graft took well.
DISCUSSION
NF is a devastating infectious disease with 0.04 cases per 1000 person-years in the general population.12 The mortality rate is 25% to 30%12 and the most common pathogen in type II necrotizing fasciitis is S pyogenes.12 Without surgical intervention, the mortality rate may reach 100%. Survival is only possible with early diagnosis and prompt treatment. The characteristics of necrotizing fasciitis in RTX patients are poorly understood due to the rarity of NF in this population. To date, there have only been 12 cases (Table 1).1e11 An analysis of these 12 patients’
characteristics is shown in Table 2. Seventy-five percent of patients were male with a mean age of 50.8 11.5 years. As in the general population, the most common sites of involvement were the extremities (83.3%). However, the most common pathogen was fungus (36.4%) (H capsulatum in 1, C albicans in 1, C Neoformans in 1, and mucormycosis in 1). The higher incidence of fungus-related NF suggests an immunocompromised condition. There were only 2 patients with negative Gram stain results (P aeruginosa4 and E coli) and both presented with shock. To the best of our knowledge, this is the first study to report a case of E colierelated NF in a renal transplant patient. This patient’s immunocompromised status was severe due to DM, and he was still using a relatively high dose of 3 combined immunosuppressants. In addition, he experienced hypovolemic shock prior to appearance of NF symptoms. Up to 50% of patients presented with septic shock, which is considerably higher than that in the general population (20.2%).12 All patients underwent debridement as the gold standard treatment,
M M F M M 64 45 58 54 48 Alexander8 Bas¸aran9 Audard10 Abigail11 This case
2809 NA, not available; RTX, renal transplantation; PD, prednisolone; AZA, azathioprine; IVIG, intravenous immunoglobulin; CsA, cyclosporine; MPA, mycophenolate; P aeruginosa, Pseudomonas aeruginosa; S pyogenes, Streptococcus pyogenes; S pneumoniae, Streptococcus pneumoniae; E Coli, Escherichia coli; MRSA, methicillin-resistant Staphylococcus aureus; C albicans, Candida albicans; C neoformans, Cryptococcus neoformans; H capsulatum, Histoplasma capsulatum; ESRD, end-stage renal disease; mTOR, mammalian target of rapamycin.
Yes No No Yes Yes No Yes Yes Yes Yes PD, MPA, CsA PD, AZA, CsA PD, MPA, FK NA PD, MPA, FK, mTOR inhibitor Elbow Leg Leg Leg Leg 2/12 5 2 NA 16
6 3
Hepatitis B infection Systemic lupus erythematosus Nil Nil Alport’s syndrome Diabetes mellitus Diabetes mellitus, hypertension 49 37 Tang6 Asher7
M F
64 Philip5
M
S pneumoniae C neoformans MRSA Mucormycosis E coli
Rash, shock Rash Rash Rash Bullae, shock
IVIG; debridement Debridement Debridement Amputation Debridement
No No Yes Yes PD, FK 506 PD, AZA, FK 506 S pyogenes S pyogenes
Bullae, shock Rash
IVIG; amputation IVIG; debridement
Yes No PD, FK 506, MPA 3/12
Abdominal wound Hand Arm
C albicans
Rash, shock
Debridement
No Yes No No Yes Yes Yes Yes Debridement Debridement Amputation Amputation AZA AZA AZA, CsA CsA PD, PD, PD, PD, Rash Rash Bullae, shock Crepitus, shock NA H capsulatum S pyogenes P aeruginosa Perineum Arm Thigh Leg 9 17 4 6
Diabetes mellitus Rheumatoid arthritis Hypertension Hypertension, spina bifida occulta Diabetes mellitus F M M M 28 49 67 46 Majeski Wagner2 Cohen3 Tsekouras4
Survival Treatment except antibiotics Immunosuppressant Presentation Pathogen Location
Table 1. All Renal Transplant Recipients With Necrotizing Fasciitis
Time after RTX (y) Underlying Gender Age (y) Case
1
ESRD
NECROTIZING FASCIITIS IN TRANSPLANTATION
Table 2. Analysis of Factors Affecting Survival and Mortality in Renal Transplant Patients With Necrotizing Fasciitis Survival Mortality group group (n ¼ 10) (n ¼ 2)
Gender (male) 7 (70%) Age (y) 48.1 10.7 Diabetes mellitus 3 (30%) Hypertension 3 (30%) Extremities 9 (90%) Streptococcus 3 (33.3%) pyogenes Fungus 3 (33.3%) GPC 4 (44.4%) GNB 2 (22.2%) Septic shock 4 (40%) Prednisolone 10 (100%) Azathioprine 5 (55.6%) MPA 2 (22.2%) CNI inhibitor 7 (77.8%) Tacrolimus 4 (44.4%) Cyclosporine 3 (33.3%) Debridement 10 (100%) Amputation 4 (40%)
All (n ¼ 12)
P value
2 (100%) 64 1 (50%) 0 1 (50%) 0
9 (75%) 50.8 11.5 4 (33.3%) 3 (25%) 10 (83.3%) 3 (27.3%)
.371 .085 .584 .371 .166 .549
1 (50%) 1 (50%) 0 2 (100%) 2 (100%) 0 2 (100%) 2 (100%) 1 (50%) 1 (50%) 2 (100%) 0
4 5 2 6 12 5 4 8 5 4 12 4
.807 .887 .670 .121 d .154 .039 .589 .887 .658 d .166
(36.4%) (45.5%) (18.2%) (50%) (100%) (45.6%) (36.4%) (72.7%) (45.5%) (36.4%) (100%) (33.3%)
GPC, gram-positive coccus; GNB, gram-negative bacillus; CNI, calcineurin inhibitor; MPA, mycophenolate acid.
but only 33% of patients received amputation. Surprisingly, the mean mortality rate was only 16.7%. In summary, the incidence of NF in RTX patients is extremely low, fungal infection is most common, and there is an association with low blood pressure, but the overall mortality rate is low. How can the E coli not being a bystander? First of all, the most convincing evidence was the positive cultured from the necrotized muscle. Second, the patient recalled that the fall resulting from massive intestinal bleeding occurred while he was urinating. A small wound was detected over his left calf after the incident. It was very likely to be scontaminated by urine, and wound culture has confirmed E coli. The clinical course of NF beginning from the left calf is compatible with such rationale. The above factors strongly suggest that the culprit of NF is E coli. In the general population, the risk factors for mortality are long duration prior to surgical intervention, older age (>60 years old), number of comorbidities, DM, shock on admission, acute renal failure, coagulopathy or acidosis on admission, Clostridial or group A streptococcal infection, Vibrio vulnificus infection, and admission serum creatinine >2 mg/dL.12 Risk factors for NF in a renal transplant population have not been previously analyzed. Table 2 shows a trend of older age (P ¼ .085) in the mortality group compared with the survival group. Furthermore, the use of mycophenolate also appeared to be associated with an increased risk of death (P ¼ .039). Mycophenolate suppresses bone marrow, which would worsen a patient’s immunocompromised status. There were no other significant correlations with other immunocompromised factors as all RTX patients’ immune systems
2810
were already markedly suppressed using medication. Unexpectedly, the mortality rate was much lower than that in the general population (16.7% vs 25%e30%), which may have been due to earlier diagnosis and timely surgical intervention. All 12 RTX patients were all under regular outpatient follow-up and the clinicians were thus alert to early signs of infection. In conclusion, NF is very rare in patients with RTX. Older patients and use of mycophenolate are associated with an increased risk of death. However, perhaps due to earlier diagnosis, the mortality rate was lower than that in the general population. Aggressive treatment is recommended for RTX patients with NF. REFERENCES 1. Majeski JA, Rajagopalan PR, Fitts CT, et al. Necrotizing fasciitis in a renal transplant patient. South Med J. 1988;81: 1315e1316. 2. Wagner JD, Prevel CD, Elluru R. Histoplasma capsulatum necrotizing myofascitis of the upper extremity. Ann Plast Surg. 1996;36:330e333. 3. Cohen E, Korzets A, Tsalihin Y, et al. Streptococcal toxic shock syndrome complicating necrotizing fasciitis in a renal transplant patient. Nephrol Dial Transplant. 1994;9:1498e1499.
TSAI 4. Tsekouras AA, Johnson A, Miller G, Orton HI. Pseudomonas aeruginosa necrotizing fasciitis: a case report. J Infect. 1998;37: 188e190. 5. Wai PH, Ewing CA, Johnson LB, Lu AD, Attinger C, Kuo PC. Candida fasciitis following renal transplantation. Transplantation. 2001;72:477e479. 6. Tang S, Kwok TK, Ho PL, Tang WM, Chan TM, Lai KN. Necrotizing fasciitis in a renal transplant recipient treated with FK 506: the first reported case. Clin Nephrol. 2001;56:481e485. 7. Korzets A, Ori Y, Zevin D, et al. Group A streptococcal bacteraemia and necrotizing faciitis in a renal transplant patient: a case for intravenous immunoglobulin therapy. Nephrol Dial Transplant. 2002;17:150e152. 8. Imhof A, Maggiorini M, Zbinden R, Walter RB. Fatal necrotizing fasciitis due to Streptococcus pneumoniae after renal transplantation. Nephrol Dial Transplant. 2003;18:195e197. 9. Bas¸aran O, Emiroglu R, Arikan U, Karakayali H, Haberal M. Cryptococcal necrotizing fasciitis with multiple sites of involvement in the lower extremities. Dermatol Surg. 2003;29:1158e1160. 10. Audard V, Pardon A, Claude O, et al. Necrotizing fasciitis during de novo minimal change nephrotic syndrome in a kidney transplant recipient. Transpl Infect Dis. 2005;7:89e92. 11. Harada AS, Lau W. Successful treatment and limb salvage of mucor necrotizing fasciitis after kidney transplantation with posaconazole. Hawaii Med J. 2007;66:68e71. 12. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009;208:279e288.
N
ECROTIZING FASCIITIS (NF) is a devastating infectious disease in the general population. To date, it has rarely been reported in patients receiving renal transplantation (RTX), and to our knowledge, only 11 cases have been previously reported in the literature.1e11 The most common pathogen in RTX patients with NF is Streptococcus pyogenes, and outcome is considered very poor. However, due to the rarity of NF in RTX patients, the pathogens involved, risk factors for mortality, and outcomes are poorly understood. Herein, we report the first case of Escherichia colierelated necrotizing fasciitis. We also summarize all 12 cases and analyze (Mann-Whitney U test for continuous variables or chi-square test for categorical variables) the characteristics and risk factors of NF in RTX patients. This is the first reported case of E colierelated NF and the first study to present a statistical analysis of factors affecting NF in RTX patients. CASE REPORT A 48-year-old man received RTX due to reflux nephropathy-related end-stage renal disease 16 years before this admission. Renal function was 3.0 mg/dL of serum creatinine and the maintenance immunosuppressants were prednisolone (10 mg), tacrolimus (2 mg/ 12 h), and mycophenolic acid (180 mg; 4 tablets, twice daily). He also had new-onset diabetes mellitus (DM) and hypertension. Before this course of admission, he was admitted due to fever and dyspnea for one week. He was diagnosed with bacterial pneumonia based on alveolar patch on chest X-ray (CXR) and yellowish sputum. Pneumonia was much improved after 10 days of treatment with moxifloxacin, but sudden onset of tarry stool occurred, with an estimated volume of 500 g. The patient experienced syncope and fell in the bathroom. Systolic blood pressure dropped from 140 mm Hg to 80 mm Hg and heart rate increased to 140 beats per minute.
Hemoglobin dropped from 11.2 g/dL to 4.4 g/dL at the same time. Initial fluid resuscitation followed by blood transfusion were prescribed to stabilize his vital signs. Due to pulmonary edema and unclear consciousness, an endotracheal tube was inserted, and then gastroduodenoscopy was performed 4 times to stop the bleeding. The lowest hemoglobin level was 3.1 g/dL. During the final gastroduodenoscopy, an active duodenal ulcer with spurting bleeding was detected and 4 metal hemoclips were applied. Once hemoglobin and vital signs were stable, we encouraged diuresis and attempted to wean the patient off the ventilator 7 days after severe hypovolemic shock. Unfortunately, fever occurred and shock recurred. White blood cell (WBC) dropped to 2200/mm3 and thrombocytopenia was also detected (26,000/mm3). Piperacillin/tazobactam was given with fluid resuscitation. Septic workup showed pyuria (35 WBC per high-power field in urine) and clear CXR. Two hours later, skin rash was found over the patient’s right leg. There was no crepitus, ulcer, or bullae. Four hours later, the rash ascended to the right thigh and left flank (Fig 1A). Twenty hours after fever, bullae were found over left leg (Fig 1C). Fluid was not turbid and bullae had a clear base. Computed tomography was used to confirm the diagnosis of NF, which showed asymmetric fascial thickening, and fat stranding. We didn’t see gas tracking along fascial planes or any abscesses formation. Finally, 24 hours after fever, minifasciotomy was performed at bedside and dishwater-like fluid was noticed seeping from the wound (Fig 1C). NF was confirmed finally after this minifasciotomy with
From the Department of Medicine, Division of Nephrology, Taichung Veterans General Hospital and Department of Life Science, Tunghai University, Taichung, Taiwan. Address reprint requests to Shang-Feng Tsai, MD, Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, No. 160, Section 3, Chung-Kang Road, Taichung 407, Taiwan. E-mail: [email protected]
ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.02.142
Transplantation Proceedings, 45, 2807e2810 (2013)
2807
2808
TSAI
Fig 1. Skin rash, ballae, and necrotizing fasciitis. (A) Rash over whole left lower limb. (B) Necrosis tissue over fascia of muscle. (C) Bullae over left high.
dishwater-like water. Fasciotomy was performed 30 hours after this septic shock. Piperacillin/tazobactam was shifted to ertapenem and wet dressings were applied for a total of 2 months. The blood culture, urine culture, and fluid culture from NF were all E coli. He suffered from bacterial pneumonia, hypovolemic shock, and NF-related septic shock, but he was eventually saved and the graft took well.
DISCUSSION
NF is a devastating infectious disease with 0.04 cases per 1000 person-years in the general population.12 The mortality rate is 25% to 30%12 and the most common pathogen in type II necrotizing fasciitis is S pyogenes.12 Without surgical intervention, the mortality rate may reach 100%. Survival is only possible with early diagnosis and prompt treatment. The characteristics of necrotizing fasciitis in RTX patients are poorly understood due to the rarity of NF in this population. To date, there have only been 12 cases (Table 1).1e11 An analysis of these 12 patients’
characteristics is shown in Table 2. Seventy-five percent of patients were male with a mean age of 50.8 11.5 years. As in the general population, the most common sites of involvement were the extremities (83.3%). However, the most common pathogen was fungus (36.4%) (H capsulatum in 1, C albicans in 1, C Neoformans in 1, and mucormycosis in 1). The higher incidence of fungus-related NF suggests an immunocompromised condition. There were only 2 patients with negative Gram stain results (P aeruginosa4 and E coli) and both presented with shock. To the best of our knowledge, this is the first study to report a case of E colierelated NF in a renal transplant patient. This patient’s immunocompromised status was severe due to DM, and he was still using a relatively high dose of 3 combined immunosuppressants. In addition, he experienced hypovolemic shock prior to appearance of NF symptoms. Up to 50% of patients presented with septic shock, which is considerably higher than that in the general population (20.2%).12 All patients underwent debridement as the gold standard treatment,
M M F M M 64 45 58 54 48 Alexander8 Bas¸aran9 Audard10 Abigail11 This case
2809 NA, not available; RTX, renal transplantation; PD, prednisolone; AZA, azathioprine; IVIG, intravenous immunoglobulin; CsA, cyclosporine; MPA, mycophenolate; P aeruginosa, Pseudomonas aeruginosa; S pyogenes, Streptococcus pyogenes; S pneumoniae, Streptococcus pneumoniae; E Coli, Escherichia coli; MRSA, methicillin-resistant Staphylococcus aureus; C albicans, Candida albicans; C neoformans, Cryptococcus neoformans; H capsulatum, Histoplasma capsulatum; ESRD, end-stage renal disease; mTOR, mammalian target of rapamycin.
Yes No No Yes Yes No Yes Yes Yes Yes PD, MPA, CsA PD, AZA, CsA PD, MPA, FK NA PD, MPA, FK, mTOR inhibitor Elbow Leg Leg Leg Leg 2/12 5 2 NA 16
6 3
Hepatitis B infection Systemic lupus erythematosus Nil Nil Alport’s syndrome Diabetes mellitus Diabetes mellitus, hypertension 49 37 Tang6 Asher7
M F
64 Philip5
M
S pneumoniae C neoformans MRSA Mucormycosis E coli
Rash, shock Rash Rash Rash Bullae, shock
IVIG; debridement Debridement Debridement Amputation Debridement
No No Yes Yes PD, FK 506 PD, AZA, FK 506 S pyogenes S pyogenes
Bullae, shock Rash
IVIG; amputation IVIG; debridement
Yes No PD, FK 506, MPA 3/12
Abdominal wound Hand Arm
C albicans
Rash, shock
Debridement
No Yes No No Yes Yes Yes Yes Debridement Debridement Amputation Amputation AZA AZA AZA, CsA CsA PD, PD, PD, PD, Rash Rash Bullae, shock Crepitus, shock NA H capsulatum S pyogenes P aeruginosa Perineum Arm Thigh Leg 9 17 4 6
Diabetes mellitus Rheumatoid arthritis Hypertension Hypertension, spina bifida occulta Diabetes mellitus F M M M 28 49 67 46 Majeski Wagner2 Cohen3 Tsekouras4
Survival Treatment except antibiotics Immunosuppressant Presentation Pathogen Location
Table 1. All Renal Transplant Recipients With Necrotizing Fasciitis
Time after RTX (y) Underlying Gender Age (y) Case
1
ESRD
NECROTIZING FASCIITIS IN TRANSPLANTATION
Table 2. Analysis of Factors Affecting Survival and Mortality in Renal Transplant Patients With Necrotizing Fasciitis Survival Mortality group group (n ¼ 10) (n ¼ 2)
Gender (male) 7 (70%) Age (y) 48.1 10.7 Diabetes mellitus 3 (30%) Hypertension 3 (30%) Extremities 9 (90%) Streptococcus 3 (33.3%) pyogenes Fungus 3 (33.3%) GPC 4 (44.4%) GNB 2 (22.2%) Septic shock 4 (40%) Prednisolone 10 (100%) Azathioprine 5 (55.6%) MPA 2 (22.2%) CNI inhibitor 7 (77.8%) Tacrolimus 4 (44.4%) Cyclosporine 3 (33.3%) Debridement 10 (100%) Amputation 4 (40%)
All (n ¼ 12)
P value
2 (100%) 64 1 (50%) 0 1 (50%) 0
9 (75%) 50.8 11.5 4 (33.3%) 3 (25%) 10 (83.3%) 3 (27.3%)
.371 .085 .584 .371 .166 .549
1 (50%) 1 (50%) 0 2 (100%) 2 (100%) 0 2 (100%) 2 (100%) 1 (50%) 1 (50%) 2 (100%) 0
4 5 2 6 12 5 4 8 5 4 12 4
.807 .887 .670 .121 d .154 .039 .589 .887 .658 d .166
(36.4%) (45.5%) (18.2%) (50%) (100%) (45.6%) (36.4%) (72.7%) (45.5%) (36.4%) (100%) (33.3%)
GPC, gram-positive coccus; GNB, gram-negative bacillus; CNI, calcineurin inhibitor; MPA, mycophenolate acid.
but only 33% of patients received amputation. Surprisingly, the mean mortality rate was only 16.7%. In summary, the incidence of NF in RTX patients is extremely low, fungal infection is most common, and there is an association with low blood pressure, but the overall mortality rate is low. How can the E coli not being a bystander? First of all, the most convincing evidence was the positive cultured from the necrotized muscle. Second, the patient recalled that the fall resulting from massive intestinal bleeding occurred while he was urinating. A small wound was detected over his left calf after the incident. It was very likely to be scontaminated by urine, and wound culture has confirmed E coli. The clinical course of NF beginning from the left calf is compatible with such rationale. The above factors strongly suggest that the culprit of NF is E coli. In the general population, the risk factors for mortality are long duration prior to surgical intervention, older age (>60 years old), number of comorbidities, DM, shock on admission, acute renal failure, coagulopathy or acidosis on admission, Clostridial or group A streptococcal infection, Vibrio vulnificus infection, and admission serum creatinine >2 mg/dL.12 Risk factors for NF in a renal transplant population have not been previously analyzed. Table 2 shows a trend of older age (P ¼ .085) in the mortality group compared with the survival group. Furthermore, the use of mycophenolate also appeared to be associated with an increased risk of death (P ¼ .039). Mycophenolate suppresses bone marrow, which would worsen a patient’s immunocompromised status. There were no other significant correlations with other immunocompromised factors as all RTX patients’ immune systems
2810
were already markedly suppressed using medication. Unexpectedly, the mortality rate was much lower than that in the general population (16.7% vs 25%e30%), which may have been due to earlier diagnosis and timely surgical intervention. All 12 RTX patients were all under regular outpatient follow-up and the clinicians were thus alert to early signs of infection. In conclusion, NF is very rare in patients with RTX. Older patients and use of mycophenolate are associated with an increased risk of death. However, perhaps due to earlier diagnosis, the mortality rate was lower than that in the general population. Aggressive treatment is recommended for RTX patients with NF. REFERENCES 1. Majeski JA, Rajagopalan PR, Fitts CT, et al. Necrotizing fasciitis in a renal transplant patient. South Med J. 1988;81: 1315e1316. 2. Wagner JD, Prevel CD, Elluru R. Histoplasma capsulatum necrotizing myofascitis of the upper extremity. Ann Plast Surg. 1996;36:330e333. 3. Cohen E, Korzets A, Tsalihin Y, et al. Streptococcal toxic shock syndrome complicating necrotizing fasciitis in a renal transplant patient. Nephrol Dial Transplant. 1994;9:1498e1499.
TSAI 4. Tsekouras AA, Johnson A, Miller G, Orton HI. Pseudomonas aeruginosa necrotizing fasciitis: a case report. J Infect. 1998;37: 188e190. 5. Wai PH, Ewing CA, Johnson LB, Lu AD, Attinger C, Kuo PC. Candida fasciitis following renal transplantation. Transplantation. 2001;72:477e479. 6. Tang S, Kwok TK, Ho PL, Tang WM, Chan TM, Lai KN. Necrotizing fasciitis in a renal transplant recipient treated with FK 506: the first reported case. Clin Nephrol. 2001;56:481e485. 7. Korzets A, Ori Y, Zevin D, et al. Group A streptococcal bacteraemia and necrotizing faciitis in a renal transplant patient: a case for intravenous immunoglobulin therapy. Nephrol Dial Transplant. 2002;17:150e152. 8. Imhof A, Maggiorini M, Zbinden R, Walter RB. Fatal necrotizing fasciitis due to Streptococcus pneumoniae after renal transplantation. Nephrol Dial Transplant. 2003;18:195e197. 9. Bas¸aran O, Emiroglu R, Arikan U, Karakayali H, Haberal M. Cryptococcal necrotizing fasciitis with multiple sites of involvement in the lower extremities. Dermatol Surg. 2003;29:1158e1160. 10. Audard V, Pardon A, Claude O, et al. Necrotizing fasciitis during de novo minimal change nephrotic syndrome in a kidney transplant recipient. Transpl Infect Dis. 2005;7:89e92. 11. Harada AS, Lau W. Successful treatment and limb salvage of mucor necrotizing fasciitis after kidney transplantation with posaconazole. Hawaii Med J. 2007;66:68e71. 12. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009;208:279e288.