- Email: [email protected]
Streptococcal necrotizing fasciitis of the eyelids and orbit
Louise Hunt, RN, MS, CRNO
Streptococcal eyelids and Streptococcal
necrotizing orbit
necrotizing
fasciitis
fasciitis in previously
persons can develop quickly and may be difficult diagnose.
In a number
condition
has been seen originally
Intensive
antibiotic
of cases, this potentially
therapy
of the
healthy to fatal
in the eyelid and orbit.
and prompt
debridement
are
the usual course of treatment.
T
Louise Hunt is a nurse specialist in clinical physiology at Presbyterian Hospital, Oklahoma City. She is a member of the Editorial Board of Insight and has been a member of ASORN since 7 982.
Reprint requests: Louise Hunt, RN, MS, CRNO, Presbyterian Hospital, 700 N.E. 7 3th St., Oklahoma City, OK 73 7 04. Insight
1996;2 1:96-7.
Copyright 0 7 996 by the American Society of Ophthalmic Registered Nurses. 1060- 7 35X/96 $5.00 + 0
72/l/7.5764 96
Volume
he incidence of streptococcal necrotizing fasciitis in healthy persons began increasing in the 1980s. Necrotizing fasciitis, also known as streptococcal gangrene, has been characterized as being caused by “flesh-eating bacteria.” It is an infection resulting from group A P-hemolytic streptococcus and initially resembles routine cellulitis. Thirty-nine cases of streptococcal necrotizing fasciitis involving the eyelid have been reported in the literature since 1965.’ When involving the eyelid, it is a rapidly progressing infection that invades the subcutaneous tissue and epithelium. Of 18 patients in whom necrotizing fasciitis of the eyelids was diagnosed, it developed spontaneously in 28% without a history of local trauma. This acute infection appears to occur more frequently in the eyelids in women, whereas in men it is seen more frequently in the limbs or trunk. Walters2 reported one fatality directly attributable to necrotizing fasciitis of the eyelids. The mortality rate for the disease in other parts of the body ranges from 22% to 50(K3 Survival from this infection often depends on early diagnosis and treatment. A healthy 52-year-old woman was initially found to have right orbital cellulitis 12 hours after complaining of right orbital pain and edema, a headache, and fever with chills. Visual acuity was light perception, and a computed tomographic scan
XXI, No. 3, September
1996
disclosed extensive soft tissue swelling without abscess or gas. Cultures revealed group A P-hemolytic streptococcus, and a diagnosis of streptococcal gangrene was made. She continued antibiotic treatment and underwent surgical debridement of the necrotic skin, muscle, and fat of both right eyelids. Three weeks after debridement, reconstruction of the right upper eyelid was performed, and visual acuity remained light perception with the development of optic atrophy.’ A healthy 47-year-old woman had severe pain around the eyes and face and bilateral periorbital edema with necrotic ulcerations of the eyelids after surgical excision of a small sebaceous cyst on the forehead. Edema continued to the neck. The necrotic regions of the eyelids were debrided, and she received antibiotic treatment for 2 weeks. A week later progressive facial and periorbital edema with erythema developed. Antibiotic therapy was resumed. Later bilateral Z-plasties of the medial canthi were required because of severe contractures that obscured her vision. Visual acuity was normal.’ The fatal case of necrotizing fasciitis of the eyelid occurred in a previously healthy 35year-old man who was initially seen because of increasing redness and swelling of the right upper eyelid 2 days after he had been poked in the right eye by his daughter. She was playing with a guinea pig when the accident occurred. On exam-
INSIGHT The Journal of the American Society of Ophthalmic
Registered Nurses, Inc.
Hunt ination he was febrile, visual acuity was reduced, and marked edema of the eyelids extended to the temple and the mouth. There was copious purulent drainage from the eye. The initial diagnosis was preseptal cellulitis with septicemia. Antibiotics were given intravenously and topically. The results of skull x-ray examination were negative, and his condition improved, but swelling and erythema of the eyelid and face remained unchanged. He had sudden cardiorespiratory arrest 21 hours after admission, with hypoxic brain damage as a result. Results of lumbar punctures and computed tomographic brain scan were normal. A violet hue and bullae developed on the eyelids, then dark areas of facial necrosis. Cultures grew Streptococcusviridans and pyogenes,and Staphylococcusahs. Despite surgical debridement of the face, eyelids, and scalp he died 11 days after admission.* Four cases have been described in the literature of necrotizing fasciitis resulting from superinfection of chickenpox skin lesions in children. The skin involved is initially erythematous, tender, swollen, and painful. Fever is present, and the skin color becomes a dusky blue with the possibility of blisters developing. The skin then becomes gangrenous and may slough if left untreated. Intravenous fluids, combined with antibiotics, and early aggressive surgical debridement are essential. Special wound care and skin grafting are often necessary.”
Necrotizing fasciitis occurs at all ages and may be difficult to diagnose in the early stages. Other terms for necrotizing fasciitis are necrotizing erysipelas and gangrenous erysipelas. Viruses, fungi, chemicals, anthrax or diphtheria bacteria, syphilis, vasculitis, and venoms from the brown recluse house spider, the water moccasin snake, or the jellyfish can cause acute necrosis.’ The severe group A streptococcus infection has been reported throughout the United States, Europe, and Australia and as occurring in healthy persons. Early diagnosis of the infection, intensive antibiotic treatment, and prompt surgical debridement are usually the course of treatment.5 References 1. Shayegani A, MacFarlane D, Kazim M, Grossman ME. Streptococcal gangrene of the eyelids and orbit. Am J Ophthalmol 1995;120: 784-92. 2. Walters R. A fatal case of necrotizing fasciitis of the eyelid. Br J Ophthalmol 1988;72:42831. 3. Overholt EM, Flint PW, Overholt EL, Murakami CS. Necrotizing fasciitis of the eyelids. Oto laryngol Head Neck Surg 1992;106:339-44. 4. Falcone PA, Pricolo VE, Edstrom LE. Necrotizing fasciitis as a complication of chickenpox. Clin Pediatr 1988;27:339-43. 5. Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis 1992;14:2-13.
‘-I=: = Julurnax,~~b*~~ stivims Mosby-Year Book, Inc. 11830 Westline Industrial Drive, St. Louis, MO 63146-3318 Phone: (800) 453-4351 or (314) 453-4351 Fax: (314) 432-1158 e-mail: [email protected] INSlGtIT
The Journal of the American Society of Ophthalmic
Registered Nurses, Inc.
Volume XXI, No. 3, September 1996
97
Streptococcal eyelids and Streptococcal
necrotizing orbit
necrotizing
fasciitis
fasciitis in previously
persons can develop quickly and may be difficult diagnose.
In a number
condition
has been seen originally
Intensive
antibiotic
of cases, this potentially
therapy
of the
healthy to fatal
in the eyelid and orbit.
and prompt
debridement
are
the usual course of treatment.
T
Louise Hunt is a nurse specialist in clinical physiology at Presbyterian Hospital, Oklahoma City. She is a member of the Editorial Board of Insight and has been a member of ASORN since 7 982.
Reprint requests: Louise Hunt, RN, MS, CRNO, Presbyterian Hospital, 700 N.E. 7 3th St., Oklahoma City, OK 73 7 04. Insight
1996;2 1:96-7.
Copyright 0 7 996 by the American Society of Ophthalmic Registered Nurses. 1060- 7 35X/96 $5.00 + 0
72/l/7.5764 96
Volume
he incidence of streptococcal necrotizing fasciitis in healthy persons began increasing in the 1980s. Necrotizing fasciitis, also known as streptococcal gangrene, has been characterized as being caused by “flesh-eating bacteria.” It is an infection resulting from group A P-hemolytic streptococcus and initially resembles routine cellulitis. Thirty-nine cases of streptococcal necrotizing fasciitis involving the eyelid have been reported in the literature since 1965.’ When involving the eyelid, it is a rapidly progressing infection that invades the subcutaneous tissue and epithelium. Of 18 patients in whom necrotizing fasciitis of the eyelids was diagnosed, it developed spontaneously in 28% without a history of local trauma. This acute infection appears to occur more frequently in the eyelids in women, whereas in men it is seen more frequently in the limbs or trunk. Walters2 reported one fatality directly attributable to necrotizing fasciitis of the eyelids. The mortality rate for the disease in other parts of the body ranges from 22% to 50(K3 Survival from this infection often depends on early diagnosis and treatment. A healthy 52-year-old woman was initially found to have right orbital cellulitis 12 hours after complaining of right orbital pain and edema, a headache, and fever with chills. Visual acuity was light perception, and a computed tomographic scan
XXI, No. 3, September
1996
disclosed extensive soft tissue swelling without abscess or gas. Cultures revealed group A P-hemolytic streptococcus, and a diagnosis of streptococcal gangrene was made. She continued antibiotic treatment and underwent surgical debridement of the necrotic skin, muscle, and fat of both right eyelids. Three weeks after debridement, reconstruction of the right upper eyelid was performed, and visual acuity remained light perception with the development of optic atrophy.’ A healthy 47-year-old woman had severe pain around the eyes and face and bilateral periorbital edema with necrotic ulcerations of the eyelids after surgical excision of a small sebaceous cyst on the forehead. Edema continued to the neck. The necrotic regions of the eyelids were debrided, and she received antibiotic treatment for 2 weeks. A week later progressive facial and periorbital edema with erythema developed. Antibiotic therapy was resumed. Later bilateral Z-plasties of the medial canthi were required because of severe contractures that obscured her vision. Visual acuity was normal.’ The fatal case of necrotizing fasciitis of the eyelid occurred in a previously healthy 35year-old man who was initially seen because of increasing redness and swelling of the right upper eyelid 2 days after he had been poked in the right eye by his daughter. She was playing with a guinea pig when the accident occurred. On exam-
INSIGHT The Journal of the American Society of Ophthalmic
Registered Nurses, Inc.
Hunt ination he was febrile, visual acuity was reduced, and marked edema of the eyelids extended to the temple and the mouth. There was copious purulent drainage from the eye. The initial diagnosis was preseptal cellulitis with septicemia. Antibiotics were given intravenously and topically. The results of skull x-ray examination were negative, and his condition improved, but swelling and erythema of the eyelid and face remained unchanged. He had sudden cardiorespiratory arrest 21 hours after admission, with hypoxic brain damage as a result. Results of lumbar punctures and computed tomographic brain scan were normal. A violet hue and bullae developed on the eyelids, then dark areas of facial necrosis. Cultures grew Streptococcusviridans and pyogenes,and Staphylococcusahs. Despite surgical debridement of the face, eyelids, and scalp he died 11 days after admission.* Four cases have been described in the literature of necrotizing fasciitis resulting from superinfection of chickenpox skin lesions in children. The skin involved is initially erythematous, tender, swollen, and painful. Fever is present, and the skin color becomes a dusky blue with the possibility of blisters developing. The skin then becomes gangrenous and may slough if left untreated. Intravenous fluids, combined with antibiotics, and early aggressive surgical debridement are essential. Special wound care and skin grafting are often necessary.”
Necrotizing fasciitis occurs at all ages and may be difficult to diagnose in the early stages. Other terms for necrotizing fasciitis are necrotizing erysipelas and gangrenous erysipelas. Viruses, fungi, chemicals, anthrax or diphtheria bacteria, syphilis, vasculitis, and venoms from the brown recluse house spider, the water moccasin snake, or the jellyfish can cause acute necrosis.’ The severe group A streptococcus infection has been reported throughout the United States, Europe, and Australia and as occurring in healthy persons. Early diagnosis of the infection, intensive antibiotic treatment, and prompt surgical debridement are usually the course of treatment.5 References 1. Shayegani A, MacFarlane D, Kazim M, Grossman ME. Streptococcal gangrene of the eyelids and orbit. Am J Ophthalmol 1995;120: 784-92. 2. Walters R. A fatal case of necrotizing fasciitis of the eyelid. Br J Ophthalmol 1988;72:42831. 3. Overholt EM, Flint PW, Overholt EL, Murakami CS. Necrotizing fasciitis of the eyelids. Oto laryngol Head Neck Surg 1992;106:339-44. 4. Falcone PA, Pricolo VE, Edstrom LE. Necrotizing fasciitis as a complication of chickenpox. Clin Pediatr 1988;27:339-43. 5. Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis 1992;14:2-13.
‘-I=: = Julurnax,~~b*~~ stivims Mosby-Year Book, Inc. 11830 Westline Industrial Drive, St. Louis, MO 63146-3318 Phone: (800) 453-4351 or (314) 453-4351 Fax: (314) 432-1158 e-mail: [email protected] INSlGtIT
The Journal of the American Society of Ophthalmic
Registered Nurses, Inc.
Volume XXI, No. 3, September 1996
97