|Year : 2015 | Volume
| Issue : 3 | Page : 188-190
Anterior chest wall an unusual site for necrotizing fasciitis
Akhil Kumar Gupta1, Mithilesh Kumar Pandey2, Puneet Gupta3, Ajay Kumar Khanna3
1 Department of General Surgery, Muzaffarnagar Medical College and Hospital, Muzaffarnagar, India
2 Department of Neurosurgery, Nil Ratan Sirkar Medical College and Hospital, Kolkata, West Bengal, India
3 Department of Neurosurgery Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||9-Dec-2015|
Mithilesh Kumar Pandey
Department of Neurosurgery, Nil Ratan Sirkar Medical College and Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Necrotizing soft tissue infections are uncommon, seen most frequently in immune-compromised patients. The infections occur most frequently along the lower aspects of the body, such as the legs, perineum, and lower abdomen. It is extremely uncommon for necrotizing fasciitis to occur along the chest wall, with only a few of such cases have been reported. We discuss a case of anterior chest wall necrotizing fasciitis that involves the areola and infra axillary region with their successful management.
Keywords: Anterior chest wall, necrotizing fasciitis, necrotizing soft tissue infections
|How to cite this article:|
Gupta AK, Pandey MK, Gupta P, Khanna AK. Anterior chest wall an unusual site for necrotizing fasciitis. Saudi J Health Sci 2015;4:188-90
| Introduction|| |
Carrying an inherently high mortality rate between, 30% and 76%, when occurring in other regions of the body, necrotizing fasciitis of the chest wall carries with it a particularly poor prognosis. Early diagnosis and treatment are the two main factors
responsible for the prognosis  and requires special management concerned with respect to early starting of broad spectrum antibiotics, debridement to prevent life threatening sepsis and delayed surgical reconstruction.
| Case Report|| |
A 64 years male patient presented to the emergency department with features of shock and respiratory distress. The patient was admitted in ICU and resuscitated with IV fluid, ionotropes, and high flow oxygen. A broad spectrum antibiotics [Piperacillin plus Tazobactum, Amikacin and Ornidazole] was started.
On detailed inquiry the patient started rt. anterior chest wall painful swelling with redness of skin and high grade fever 12 days ago. After 4 to 5 days the swelling was burst out spontaneously and skin colour changes to blackish with foul smell discharge then he consulted first to his home physician where some cleaning and debridement of wound has done. There was no history of trauma, diabetes mellitus, tuberculosis and steroid or chemotherapy drug intake.
}On examination a 16 × 14 cm size gangrenous ulcer present at right anterior chest wall involving the right areola, sparing the nipple and extending towards right axilla. The ulcer floor contains the slough and necrotic tissue with foul smell discharge [Figure 1]a and [Figure 1]b.
|Figure 1: (a and b) Clinical photograph showing anterior chest wall wound following necrotizing fasciitis|
Click here to view
Laboratory analysis revealed Hb 11.5 gm/dl, WBC 21000/cumm, polymorphs 88%, blood sugar 89 mg/dl and HIV was nonreactive.
Aggressive debridement of subcutaneous tissue and involved pectoralis fascia with necrosed muscle fibre of pectoralis major was done. The pus was sent for culture-sensitivity and debrided material for biopsy. Multiple times ulcer debridement was done, within a period of 3 weeks.
Pus culture was shown staphylococcus aureus organism sensitive to Imipenem and Amoxycillin. Patient was put on antibiotics according to sensitivity.
The Histopathological findings showed features of necrosis involving skin, subcutaneous tissue and muscle fibres of anterior chest wall with polymorphs infiltration and intravascular coagulation in the dermis.
After 4 wks the healthy granulation tissue appeared [Figure 2]. The defect was closed with local skin flap [Figure 3]. Nipple was preserved. The flap was healthy and wound healed completely. The patient was followed up for 1 year and remained asymptomatic.
|Figure 2: Wound 4 weeks after multiple debridements' was showing healthy granulation tissue|
Click here to view
| Discussion|| |
Necrotizing fasciitis is a derma-hypodermitis affecting the soft tissue and muscular fascia. An uncommon infection caused by microorganisms called 'flesh eating bacteria, mainly represented by group A beta-haemolytic streptococcus. Necrotizing fasciitis remains a life-threatening condition occurring most commonly in immune-compromised patient (diabetics, alcoholics, immunosuppressed patients), in drug users, and in patients with peripheral vascular disease, although it can also occur in young, previously healthy individuals.
Its location to the chest wall is extremely rare., In a large series of 166 patients with, necrotizing fasciitis the extremities were the most common site of infection (57.8%), followed by the abdomen (12.1%), perineum (12.1%), buttocks (10.2%), head and neck (8%), and chest (5%).
These infections are often multimicrobial, although a single organism may be responsible in as many as 77% of infected patients. When a single organism is responsible, group A streptococci and clostridium perfringens have been among the most frequently isolated pathogens. Monomicrobial infections often present in a fulminate fashion, with systemic toxicity highlighted by fever, leukocytosis and, occasionally, shock as in our case. In contrast, polymicrobial infections may present in a more insidious manner.
These infections are caused by synergy among anaerobes and facultative aerobes, involving both gram negative and gram-positive organisms, and can
affect any and all layers of soft tissue, including skin, fat, fascia, and muscle.
Numerous inciting incidents have been implicated, including major or minor trauma, unrecognized lower extremity ulcerations and minor infections, perirectal abscesses, and postoperative mishaps often involving violation of the gastrointestinal tract.
Severe necrotizing soft tissue infections involving the upper body and chest wall, however, are distinctly
uncommon, thoracic location is most frequently reported after chest drainage or after thoracic surgery. However, contagions from empyema have been reported.,,
But in our case no inciting events were detected.
The characteristics of necrotizing fasciitis in the chest wall adjacent to the axilla are quite different from other sites; axillary necrotizing fasciitis may be recorded as chest wall necrotizing fasciitis. Many cases were associated with an underlying condition or surgical procedures such as tube thoracostomy for empyema and esophagectomy for cancer.
Clinical features of chest wall necrotizing soft tissue infection are similar to those seen at other sites: Wound pain, skin blistering, crepitus, foul-smelling watery discharge from the wound, and dramatic deterioration in the patient's condition.
Because there are few early symptoms (cutaneous manifestations appear late), diagnosis is difficult and may require blood culture, wound culture, and radiographic imaging.
Because of the delay in diagnosis and inadequate debridement, chest wall necrotizing fasciitis has been highly lethal. It appears that factors other than bacteriology can account for the extremely high fatality rate in chest wall necrotizing fasciitis. Most of the patients reported to have died with the condition had chronic predisposing conditions, and more than 80% experienced significant diagnostic delays before treatment was initiated.,
The antibiotic treatment must be started immediately, even before the results of the microbiological analyses. Antibiotics are usually adjuvant to the surgical treatment because the local vascular thrombosis results in poor antibiotic tissue diffusion.
The objective of the antibiotic treatment is to limit the progression of the infection. The recommended antibiotic treatment consists in the association of beta-lactames, imidazole, and ± aminoglycosides.
A specific surgical approach is required to perform early and adequate debridement, depending on the body region involved. The infection may be widespread in the upper extremity and the trunk.
Treatment of necrotizing fasciitis entails a radical excisional debridement. The extent of debridement has been a topic of debate. Sarani et al. recommended that the excision boundaries in necrotizing fasciitis should be at least as wide as the rim of cellulites.
Wong et al. proposed a different approach to the debridement in necrotizing fasciitis, involving the classification of the affected area into the three surgical zones: (i) Necrotic tissue, which is completely excised; (ii) infected but potentially salvageable soft tissue, which is carefully assessed and progressively cut back; and (iii) non-infected skin, which is left alone.
For the widespread redness on the trunk in this case, we choose the latter; the erythematous skin did not become necrotic.
Wound closure has been difficult in patients who survived the initial septic phase. The literatures tell us for the reconstruction of defect after necrotizing fasciitis to follow the step ladder pattern of repair.
| Conclusion|| |
In conclusion the necrotizing fasciitis progresses to a general septic appearance and spreads more through muscle and subcutaneous cellular tissue. It's may lead to fatal outcome not only because of its severity, but delay in diagnosing it during the early stages due to the paucity of skin findings early in the disease. Early starting of broad spectrum antibiotic with aggressive debridement can save the patient.
| Acknowledgments|| |
Very much thanks to Dr. Kaushik Roy and Prof. Suniti Kumar Saha.
| References|| |
McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558-65.
Urschel JD, Takita H, Antkowiak JG. Necrotizing soft tissue infections of the chest wall. Ann Thorac Surg 1997;64:276-9.
Safran DB, Sullivan WG. Necrotizing fasciitis of the chest wall. Ann Thorac Surg 2001;72:1362-4.
Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E. Predictors of mortality and limb loss in necrotizing soft tissue infections. Arch Surg 2005;140:151-8.
Giuliano A, Lewis F
Jr, Hadley K, Blaisdell FW. Bacteriology of necrotizing fasciitis. Am J Surg 1977;134:52-7.
McHenry CR, Malangoni MA. Necrotizing soft tissue infections. In: Fry DE, editor. Surgical Infections. Boston: Little Brown and Company; 1994. p. 145-59.
Birnbaum DJ, D'Journo XB, Casanova D, Thomas PA. Necrotizing fasciitis of the chest wall. Interact Cardiovasc Thorac Surg 2010;10:483-4.
Kalkat MS, Rajesh PB, Hendrickse C. Necrotizing fasciitis of chest wall complicating empyema thoracis. Interact Cardiovasc Thorac Surg 2003;2:358-60.
Yamasaki O, Nagao Y, Sugiyama N, Otsuka M, Iwatsuki K. Surgical management of axillary necrotizing fasciitis: A case report. J Dermatol 2012;39:309-11.
Chen YM, Wu MF, Lee PY, Su WJ, Perng RP. Necrotizing fasciitis: Is it a fatal complication of tube thoracostomy?--Report of three cases. Respir Med 1992;86:249-51.
Krol JR, Kwee KW, Thijs LG. Rapidly progressive septic shock, associated with necrotizing fasciitis. Intensive Care Med 1982;8:235-7.
Eugster T, Aeberhard P, Reist K, Sakmann K. Necrotizing fasciitis caused by beta-hemolytic streptococci with fatal outcome--a case report. Swiss Surg 1997;3:117-20.
Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: Current concept and review of the literature. J Am Coll Surg 2009;208:279-88.
Wong CH, Yam AK, Tan AB, Song C. Approach to debridement in necrotizing fasciitis. Am J Surg 2008;196:e19-24.
[Figure 1], [Figure 2], [Figure 3]