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A case of periorbital necrotizing fasciitis rapidly progressing to severe multiorgan failure

A case of periorbital necrotizing fasciitis rapidly progressing to severe multiorgan failure Periorbital necrotizing fasciitis (PNF) is a severe suppurative infection of the subcutaneous tissue and underlying fascia of the peri- orbital region. Typically, the course of PNF is milder and has a better prognosis than that of necrotizing fasciitis in other parts of the body. As such, this disease is thought to be associated with a significantly smaller risk of morbidity and mortality. Nevertheless, it is a rare and devastating condition that can lead to disfigurement, blindness and death. Early recognition is critical to improved patient outcomes. Here, we describe a case of PNF in a 60-year-old male that rapidly progressed to widespread sys- temic involvement and severe multiorgan failure requiring ventilatory, cardiovascular and renal support. Treatment included broad-spectrum antibiotics, intravenous immunoglobulin and surgical debridement. This case highlights the life-threatening nature of PNF, as demonstrated by rapid progression to multiorgan dysfunction and the need of an urgent surgical intervention. Clostridium species or gram-negative bacteria; type IV is due to INTRODUCTION fungi. Necrotizing fasciitis (NF) is a fulminant life-threatening infection Morbidity and mortality of NF are high but vary between that affects the skin and subcutaneous tissue. It is characterized bodily regions. Periorbital NF (PNF) is a rare form of NF with UK by rapidly spreading necrosis that tracks along the superficial incidence of 0.24 per 1 000 000 per year [1]. It is generally fascial plane. Most commonly NF develops in areas of compro- thought to be the least severe form of NF with the best progno- mised skin-integrity (e.g. following surgery or trauma) which sis [2]. Multiorgan involvement is uncommon. Lower rates of allows for microbial invasion, however, it can also occur in morbidity and mortality are related to earlier presentation and unspoiled tissue. Other risk factors include immunocompromise diagnosis, higher vascularity of the region leading to improved and co-existence of systemic disease such as diabetes mellitus. antimicrobial agent penetration, and anatomical structure with Typical presentation involves severe pain disproportionate to the the orbital septum hindering posterior progression [2]. apparent area involved, erythema, oedema and raised tempera- Although rare, and often associated with a milder clinical ture. This is associated with a rapid progression and deterioration. course than NF in the extremities, abdomen or perineum, PNF Diagnosisisoften difficult, requiring a high level of suspicion, as can lead to severe complications. Here we describe a case when clinical signs fail to denote the severity of the condition. PNF rapidly progressed to septic shock and multiorgan failure. NF can be classified into four subtypes depending on the causative pathogen: type I is the most prevalent (70–80% of CASE REPORT cases) and is polymicrobial in origin; type II is due to monomi- crobial infection with group A Streptococcus alone or in associ- A 60-year-old male with a past medical history of hypertension ation with Staphylococcus aureus; type III is due to infection with presented to the emergency department of a District General Received: February 15, 2018. Accepted: April 14, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article-abstract/2018/4/rjy083/4990324 by Ed 'DeepDyve' Gillespie user on 16 October 2019 2 P. Eiben and S. Rodriguez-Villar Figure 1: Axial CT angiogram carotids images showing (A) diffuse left periorbital region involvement with no retro-orbital or extra-orbital collections. (B) No evidence of vessel thrombosis. Table 1 Laboratory results. Days of hospital admission 1234510 15 19 3 months CRP (mg/l) 560 390 384.5 212.7 95.4 35.5 13.8 4.9 <0.2 WBC (11^9/l) 19.80 16.57 18.98 18.35 27.33 22.63 10.08 7.12 13.02 Neutrophils (%) 18.60 14.91 17.04 15.40 20.22 17.29 6.33 3.35 6.61 Lymphocytes (%) 0.70 0.75 1.23 1.71 4.37 3.96 2.98 3.03 5.68 Hb (g/l) 154 102 95 90 96 87 75 75 133 Creatinine (umol/l) 792 711 379 320 324 192 298 221 109 K (mmol/l) 3.7 4.2 4.1 4.1 4.1 4.7 5.3 4.8 4.4 Blood glucose (mmol/l) 7.1 10.3 8.9 7.1 7.7 5.3 N/A N/A N/A Figure 2: (A) An image of the patient post-intubation demonstrating marked left periorbital oedema and violaceous erythematous and necrotic changes. (B) A close- up of the left periorbital region skin changes. Hospital with a 7-day history of a worsening left eye swelling, supplementation. A computed tomography (CT) carotid angio- pain and erythema. There was no history of previous trauma, gram revealed a diffuse left orbital cellulitis with no intraorbital sinus disease or recent surgery. On arrival, clinical examination collection (Fig. 1A). There was no evidence of intracerebral vas- revealed that the patient was in circulatory shock with signs of cular thrombosis (Fig. 1B). Blood tests showed an inflammatory sepsis. Immediate treatment for a suspected septic shock due to picture (Table 1). left periorbital cellulitis was started with broad-spectrum intra- Despite initial treatment, the patient continued to rapidly venous (IV) antibiotics (Vancomycin, Gentamycin, Meropenem deteriorate. A few hours after presentation, he developed and Clindamycin), aggressive fluid resuscitation and oxygen respiratory compromise and haemodynamic instability. He was Downloaded from https://academic.oup.com/jscr/article-abstract/2018/4/rjy083/4990324 by Ed 'DeepDyve' Gillespie user on 16 October 2019 A case of periorbital necrotizing fasciitis 3 Figure 3: Lateral views demonstrating extension of the swelling over the lateral aspect of the face (A) and scalp (B). Purulent material can be seen weeping from the tissue. Table 2 Microbiology results. Days of hospital Site Cultured organism Sensitivity admission 1 Left eye swabs Staphylococcus Aureus Penicillin, erythromycin, trimethoprim, gentamycin, flucloxacillin Beta-Haemolytic Group A Streptococcus Penicillin, erythromycin, first generation cephalosporin, chloramphenicol, clarithromycin 1 Blood cultures Beta-Haemolytic Group A Streptococcus Penicillin intubated for ventilatory support and vasopressor treatment was commenced. Due to the acute progression to multiorgan failure, PNF was suspected (Figs 2 and 3). The patient was started on intravenous immunoglobulin (IVIg) and emergency transferred to a specialist centre for surgical intervention. Pre- procedure ophthalmology examination revealed left periorbital swelling, with necrosis of the upper eyelid and a suspected abscess of the lower eyelid. The patient underwent debride- ment of the upper and lower eyelids and periorbital tissues, with the affected tissue removed back to bleeding edges. Intra- operative findings were consistent with NF. Post-operatively, the patient was transferred to the inten- sive care unit for management of septic shock and multiorgan failure secondary to PNF. Initially, he required respiratory sup- port, vasopressors and inotropes for cardiovascular comprom- ise, and renal replacement therapy for acute kidney injury. Following microbiology advice, antibiotics were changed to Meropenem, Clindamycin, Ceftriaxone and Linezolid. Beta- haemolytic Group A Streptococcus (invasive group A streptococ- Figure 4: Axial CT Orbits performed on Day 7 post-debridement, showing cus, IGAS) was isolated from blood cultures and tissue swabs improved left periorbital soft tissue swelling. No post-septal involvement, orbit (Table 2). breach or identifiable collections. The patient’s condition began to stabilize 24 hours after the surgical intervention. A repeat CT orbit revealed persistent, though reduced, soft tissue swelling with no orbital breach or consequence of pathogenic invasion and polymorphonuclear collections (Fig. 4). The patient improved and was discharged leucocyte infiltration leading to vascular thrombosis and from hospital 19 days after admission. At 3 months, the ischaemia with subsequent gangrene of the subcutaneous fat wounds had healed and there was no visual deficit (Fig. 5). He and dermis. is awaiting reconstructive surgery under the maxillofacial and The thinness of the skin and a relative lack of subcutaneous the oculoplastic teams. tissue in the periorbital region mean that the necrosis occurs quicker than in other parts of the body with gangrene present as early as 24 hours. The most common type of PNF is NF type DISCUSSION II [5]. Complications occur in over 66% of cases of PNF with mor- NF of the head and neck region can develop secondary to pene- trating or blunt trauma, dermatologic infection or pruritus, oto- tality of 10% [1]. Comparatively, mortality of NF on average ranges between 20% and 35% [4, 6], but has been cited as high logic infection, salivary gland infection, cervical adenitis or peritonsillar abscess [3]. Interestingly, no precipitating factor is as 76% [7]. While the risk of septic shock in PNF is about 20%, it is twice as high in NF elsewhere in the body [2]. To further found in about 30% of cases [4]. Necrosis develops as a Downloaded from https://academic.oup.com/jscr/article-abstract/2018/4/rjy083/4990324 by Ed 'DeepDyve' Gillespie user on 16 October 2019 4 P. Eiben and S. Rodriguez-Villar evidence, it is a general belief that IVIg is beneficial in severe NF. IVIg is an immunomodulator with anti-inflammatory properties that among others, facilitates antibody-mediated neutralization of bacterial superantigens and toxins [10]. Our patient was treated with IVIg and we can report positive outcomes. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Flavahan PW, Cauchi P, Gregory ME, Foot B, Drummond SR. Incidence of periorbital necrotizing fasciitis in the UK popu- lation: a BOSU study. Br J Ophthalmol 2014;98:1177–80. 2. Rajak SN, Figueira EC, Haridas AS, Satchi K, Uddin JM, McNab AA, et al. Periocular necrotizing fasciitis: a multicen- ter case series. Br J Ophthalmol 2016;100:1517–20. 3. Ali AH, Salahuddin Z, Ismail H, Sofi AIM, Mohamad I. Debridement of facial necrotizing fasciitis via bicoronal Figure 5: An image 3 months post-surgery showing good wound healing and a flap. Egypt J Ear N Throat Allied Sci 2017;18:287–9. residual ectropion on the left upper eyelid. 4. Lazzeri D, Lazzeri S, Figus M, Tascini C, Bocci G, Colizzi L, et al. Periorbital necrotizing fasciitis. Br J Ophthalmol 2010;94: illustrate the presumed difference in severity between PNF and 1577–85. NF, some case reports describe successful management of PNF 5. Alvarez Hernandez DA, Chavez AG, Rivera AS. Facial necro- with medical management alone [2, 8, 9]. Despite the apparent tizing fasciitis in adults. A systematic review. Heighpubs milder nature of PNF, as demonstrated by the described above Otolaryngol Rhinol 2017;1:020–31. case, it is associated with serious complications and should be 6. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low managed as a life-threatening condition. CO. Necrotizing fasciitis: clinical presentation, microbiol- Visual loss occurs in over 13% of patients [8] and is attribut- ogy, and determinants of mortality. J Bone Joint Surg Am able to orbital spread, corneal perforation or central retinal 2003;85-A:1454–60. artery occlusion. Other complications include vascular throm- 7. van Stigt SFL, de Vries J, Bijker JB, Mollen RMHG, Hekma EJ, bosis, facial disfigurement, and functional defects. The most Lemson SM, et al. Review of 58 patients with necrotizing common causes of death are septic shock and multiorgan fasciitis in the Netherlands. World J Emerg Surg 2016;11:21 failure. DOI10.11.1186/s13017-016-0080-7. Management involves aggressive antimicrobial treatment 8. Mehta R, Kumar A, Crock C, McNab A. Medical management and surgical debridement of the necrotic tissue. Notably, vessel of periorbital necrotizing fasciitis. Orbit 2013;32:253–5. thrombosis around the affected site means that intravenous 9. Mutamba A, Verity DH, Rose GE. ‘Stalled’ periocular necro- antimicrobial treatment may not be able to reach the tissue redu- tizing fasciitis: early effective treatment of host genetic cing its effectiveness. Surgical excision mechanically decreases determinants? Eye 2013;27:432–7. the number of organisms and reduces toxin load. 10. Koch C, Hecker A, Grau V, Padberg W, Wolff M, Henrich M. Although alternative therapies such as hyperbaric oxygen ther- Intravenous immunoglobulin in necrotizing fasciitis—a apy, negative pressure wound therapy or IVIg have been sug- case report and review of recent literature. Ann Med Surg gested as adjuncts, their use is controversial. Despite contrasting 2015;4:260–3. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

A case of periorbital necrotizing fasciitis rapidly progressing to severe multiorgan failure

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Periorbital necrotizing fasciitis (PNF) is a severe suppurative infection of the subcutaneous tissue and underlying fascia of the peri- orbital region. Typically, the course of PNF is milder and has a better prognosis than that of necrotizing fasciitis in other parts of the body. As such, this disease is thought to be associated with a significantly smaller risk of morbidity and mortality. Nevertheless, it is a rare and devastating condition that can lead to disfigurement, blindness and death. Early recognition is critical to improved patient outcomes. Here, we describe a case of PNF in a 60-year-old male that rapidly progressed to widespread sys- temic involvement and severe multiorgan failure requiring ventilatory, cardiovascular and renal support. Treatment included broad-spectrum antibiotics, intravenous immunoglobulin and surgical debridement. This case highlights the life-threatening nature of PNF, as demonstrated by rapid progression to multiorgan dysfunction and the need of an urgent surgical intervention. Clostridium species or gram-negative bacteria; type IV is due to INTRODUCTION fungi. Necrotizing fasciitis (NF) is a fulminant life-threatening infection Morbidity and mortality of NF are high but vary between that affects the skin and subcutaneous tissue. It is characterized bodily regions. Periorbital NF (PNF) is a rare form of NF with UK by rapidly spreading necrosis that tracks along the superficial incidence of 0.24 per 1 000 000 per year [1]. It is generally fascial plane. Most commonly NF develops in areas of compro- thought to be the least severe form of NF with the best progno- mised skin-integrity (e.g. following surgery or trauma) which sis [2]. Multiorgan involvement is uncommon. Lower rates of allows for microbial invasion, however, it can also occur in morbidity and mortality are related to earlier presentation and unspoiled tissue. Other risk factors include immunocompromise diagnosis, higher vascularity of the region leading to improved and co-existence of systemic disease such as diabetes mellitus. antimicrobial agent penetration, and anatomical structure with Typical presentation involves severe pain disproportionate to the the orbital septum hindering posterior progression [2]. apparent area involved, erythema, oedema and raised tempera- Although rare, and often associated with a milder clinical ture. This is associated with a rapid progression and deterioration. course than NF in the extremities, abdomen or perineum, PNF Diagnosisisoften difficult, requiring a high level of suspicion, as can lead to severe complications. Here we describe a case when clinical signs fail to denote the severity of the condition. PNF rapidly progressed to septic shock and multiorgan failure. NF can be classified into four subtypes depending on the causative pathogen: type I is the most prevalent (70–80% of CASE REPORT cases) and is polymicrobial in origin; type II is due to monomi- crobial infection with group A Streptococcus alone or in associ- A 60-year-old male with a past medical history of hypertension ation with Staphylococcus aureus; type III is due to infection with presented to the emergency department of a District General Received: February 15, 2018. Accepted: April 14, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/jscr/article-abstract/2018/4/rjy083/4990324 by Ed 'DeepDyve' Gillespie user on 16 October 2019 2 P. Eiben and S. Rodriguez-Villar Figure 1: Axial CT angiogram carotids images showing (A) diffuse left periorbital region involvement with no retro-orbital or extra-orbital collections. (B) No evidence of vessel thrombosis. Table 1 Laboratory results. Days of hospital admission 1234510 15 19 3 months CRP (mg/l) 560 390 384.5 212.7 95.4 35.5 13.8 4.9 <0.2 WBC (11^9/l) 19.80 16.57 18.98 18.35 27.33 22.63 10.08 7.12 13.02 Neutrophils (%) 18.60 14.91 17.04 15.40 20.22 17.29 6.33 3.35 6.61 Lymphocytes (%) 0.70 0.75 1.23 1.71 4.37 3.96 2.98 3.03 5.68 Hb (g/l) 154 102 95 90 96 87 75 75 133 Creatinine (umol/l) 792 711 379 320 324 192 298 221 109 K (mmol/l) 3.7 4.2 4.1 4.1 4.1 4.7 5.3 4.8 4.4 Blood glucose (mmol/l) 7.1 10.3 8.9 7.1 7.7 5.3 N/A N/A N/A Figure 2: (A) An image of the patient post-intubation demonstrating marked left periorbital oedema and violaceous erythematous and necrotic changes. (B) A close- up of the left periorbital region skin changes. Hospital with a 7-day history of a worsening left eye swelling, supplementation. A computed tomography (CT) carotid angio- pain and erythema. There was no history of previous trauma, gram revealed a diffuse left orbital cellulitis with no intraorbital sinus disease or recent surgery. On arrival, clinical examination collection (Fig. 1A). There was no evidence of intracerebral vas- revealed that the patient was in circulatory shock with signs of cular thrombosis (Fig. 1B). Blood tests showed an inflammatory sepsis. Immediate treatment for a suspected septic shock due to picture (Table 1). left periorbital cellulitis was started with broad-spectrum intra- Despite initial treatment, the patient continued to rapidly venous (IV) antibiotics (Vancomycin, Gentamycin, Meropenem deteriorate. A few hours after presentation, he developed and Clindamycin), aggressive fluid resuscitation and oxygen respiratory compromise and haemodynamic instability. He was Downloaded from https://academic.oup.com/jscr/article-abstract/2018/4/rjy083/4990324 by Ed 'DeepDyve' Gillespie user on 16 October 2019 A case of periorbital necrotizing fasciitis 3 Figure 3: Lateral views demonstrating extension of the swelling over the lateral aspect of the face (A) and scalp (B). Purulent material can be seen weeping from the tissue. Table 2 Microbiology results. Days of hospital Site Cultured organism Sensitivity admission 1 Left eye swabs Staphylococcus Aureus Penicillin, erythromycin, trimethoprim, gentamycin, flucloxacillin Beta-Haemolytic Group A Streptococcus Penicillin, erythromycin, first generation cephalosporin, chloramphenicol, clarithromycin 1 Blood cultures Beta-Haemolytic Group A Streptococcus Penicillin intubated for ventilatory support and vasopressor treatment was commenced. Due to the acute progression to multiorgan failure, PNF was suspected (Figs 2 and 3). The patient was started on intravenous immunoglobulin (IVIg) and emergency transferred to a specialist centre for surgical intervention. Pre- procedure ophthalmology examination revealed left periorbital swelling, with necrosis of the upper eyelid and a suspected abscess of the lower eyelid. The patient underwent debride- ment of the upper and lower eyelids and periorbital tissues, with the affected tissue removed back to bleeding edges. Intra- operative findings were consistent with NF. Post-operatively, the patient was transferred to the inten- sive care unit for management of septic shock and multiorgan failure secondary to PNF. Initially, he required respiratory sup- port, vasopressors and inotropes for cardiovascular comprom- ise, and renal replacement therapy for acute kidney injury. Following microbiology advice, antibiotics were changed to Meropenem, Clindamycin, Ceftriaxone and Linezolid. Beta- haemolytic Group A Streptococcus (invasive group A streptococ- Figure 4: Axial CT Orbits performed on Day 7 post-debridement, showing cus, IGAS) was isolated from blood cultures and tissue swabs improved left periorbital soft tissue swelling. No post-septal involvement, orbit (Table 2). breach or identifiable collections. The patient’s condition began to stabilize 24 hours after the surgical intervention. A repeat CT orbit revealed persistent, though reduced, soft tissue swelling with no orbital breach or consequence of pathogenic invasion and polymorphonuclear collections (Fig. 4). The patient improved and was discharged leucocyte infiltration leading to vascular thrombosis and from hospital 19 days after admission. At 3 months, the ischaemia with subsequent gangrene of the subcutaneous fat wounds had healed and there was no visual deficit (Fig. 5). He and dermis. is awaiting reconstructive surgery under the maxillofacial and The thinness of the skin and a relative lack of subcutaneous the oculoplastic teams. tissue in the periorbital region mean that the necrosis occurs quicker than in other parts of the body with gangrene present as early as 24 hours. The most common type of PNF is NF type DISCUSSION II [5]. Complications occur in over 66% of cases of PNF with mor- NF of the head and neck region can develop secondary to pene- trating or blunt trauma, dermatologic infection or pruritus, oto- tality of 10% [1]. Comparatively, mortality of NF on average ranges between 20% and 35% [4, 6], but has been cited as high logic infection, salivary gland infection, cervical adenitis or peritonsillar abscess [3]. Interestingly, no precipitating factor is as 76% [7]. While the risk of septic shock in PNF is about 20%, it is twice as high in NF elsewhere in the body [2]. To further found in about 30% of cases [4]. Necrosis develops as a Downloaded from https://academic.oup.com/jscr/article-abstract/2018/4/rjy083/4990324 by Ed 'DeepDyve' Gillespie user on 16 October 2019 4 P. Eiben and S. Rodriguez-Villar evidence, it is a general belief that IVIg is beneficial in severe NF. IVIg is an immunomodulator with anti-inflammatory properties that among others, facilitates antibody-mediated neutralization of bacterial superantigens and toxins [10]. Our patient was treated with IVIg and we can report positive outcomes. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Flavahan PW, Cauchi P, Gregory ME, Foot B, Drummond SR. Incidence of periorbital necrotizing fasciitis in the UK popu- lation: a BOSU study. Br J Ophthalmol 2014;98:1177–80. 2. Rajak SN, Figueira EC, Haridas AS, Satchi K, Uddin JM, McNab AA, et al. Periocular necrotizing fasciitis: a multicen- ter case series. Br J Ophthalmol 2016;100:1517–20. 3. Ali AH, Salahuddin Z, Ismail H, Sofi AIM, Mohamad I. Debridement of facial necrotizing fasciitis via bicoronal Figure 5: An image 3 months post-surgery showing good wound healing and a flap. Egypt J Ear N Throat Allied Sci 2017;18:287–9. residual ectropion on the left upper eyelid. 4. Lazzeri D, Lazzeri S, Figus M, Tascini C, Bocci G, Colizzi L, et al. Periorbital necrotizing fasciitis. Br J Ophthalmol 2010;94: illustrate the presumed difference in severity between PNF and 1577–85. NF, some case reports describe successful management of PNF 5. Alvarez Hernandez DA, Chavez AG, Rivera AS. Facial necro- with medical management alone [2, 8, 9]. Despite the apparent tizing fasciitis in adults. A systematic review. Heighpubs milder nature of PNF, as demonstrated by the described above Otolaryngol Rhinol 2017;1:020–31. case, it is associated with serious complications and should be 6. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low managed as a life-threatening condition. CO. Necrotizing fasciitis: clinical presentation, microbiol- Visual loss occurs in over 13% of patients [8] and is attribut- ogy, and determinants of mortality. J Bone Joint Surg Am able to orbital spread, corneal perforation or central retinal 2003;85-A:1454–60. artery occlusion. Other complications include vascular throm- 7. van Stigt SFL, de Vries J, Bijker JB, Mollen RMHG, Hekma EJ, bosis, facial disfigurement, and functional defects. The most Lemson SM, et al. Review of 58 patients with necrotizing common causes of death are septic shock and multiorgan fasciitis in the Netherlands. World J Emerg Surg 2016;11:21 failure. DOI10.11.1186/s13017-016-0080-7. Management involves aggressive antimicrobial treatment 8. Mehta R, Kumar A, Crock C, McNab A. Medical management and surgical debridement of the necrotic tissue. Notably, vessel of periorbital necrotizing fasciitis. Orbit 2013;32:253–5. thrombosis around the affected site means that intravenous 9. Mutamba A, Verity DH, Rose GE. ‘Stalled’ periocular necro- antimicrobial treatment may not be able to reach the tissue redu- tizing fasciitis: early effective treatment of host genetic cing its effectiveness. Surgical excision mechanically decreases determinants? Eye 2013;27:432–7. the number of organisms and reduces toxin load. 10. Koch C, Hecker A, Grau V, Padberg W, Wolff M, Henrich M. Although alternative therapies such as hyperbaric oxygen ther- Intravenous immunoglobulin in necrotizing fasciitis—a apy, negative pressure wound therapy or IVIg have been sug- case report and review of recent literature. Ann Med Surg gested as adjuncts, their use is controversial. Despite contrasting 2015;4:260–3.

Journal

Journal of Surgical Case Reports – Oxford University Press

Published: Apr 1, 2018

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