Abstract A 49-year-old patient presented with an unusual
case of cervical necrotizing fasciitis that extended subacutely
to the upper trunk. The source of the infection was unknown.
The patient had a markedly protracted course and had severe
complications, including pneumonia, septic shock, and dis-
seminated intravascular coagulation. Following surgical deb-
ridement, split thickness skin grafting was performed from
the neck to the anterior chest wall; a subcutaneous area on the
back was debrided, the skin was not affected and the area
healed like a bipedicled flap. This paper also focuses on the
importance of intense supportive care and the clinical utility
of intravenous human immunoglobulin.
Key words Cervical necrotizing fasciitis · Intravenous
human immunoglobulin · Protracted course · Intensive
Cervical necrotizing fasciitis (CNF) is a rare, but potential-
ly fatal infection characterized by the rapid development of
gangrene in the subcutaneous tissue with subsequent ne-
crosis of the overlying skin . Extension to the lower part
of the neck has been documented in approximately half of
the reported cases; extension of CNF to the back and flank
is extremely rare [1,11]. An unusual case of CNF is report-
ed, it was successfully treated despite severe complications
and extension to the upper trunk due to delayed diagnosis.
A 49-year-old man was admitted to the Department of Neurology
with alcoholic neuropathy. He had skin necrosis from the neck to
the anterior chest wall, following a 1-week history of a small sub-
cutaneous abscess of the chin. Non-hemolytic Streptococcus mil-
leri group (SMG) was identified from sputum, blood and the ab-
scess. Anaerobic culture of those samples grew no bacteria. The
patient’s condition was thought to be an extensive cellulitis associ-
ated with severe complications, including anemia, pneumonia,
septic shock, and disseminated intravascular coagulation (DIC).
High doses of intravenous penicillin G and clindamycin, in con-
junction with panipenem-betamipron, were given. The patient re-
ceived a 5-g dose of intravenous human immunoglobulin (IVIG)
daily for 3 days. He also received continuous DIC treatment with
gabexate mesilate, heparin, and platelet transfusion.
The patient was referred to the Department of Plastic Surgery
17 days after the onset of extensive skin necrosis from the neck to
the anterior chest wall (Fig. 1). Physical examination revealed
mild loss of consciousness, cyanosis of extremities, and hypovo-
lemia . Chest radiography suggested adult respiratory distress
syndrome (ARDS) with pneumonia; a computed tomography
(CT) scan showed extensive soft tissue necrosis of the chest wall.
After a diagnosis of CNF was made, the patient was transferred to
the Intensive Care Unit (ICU) where he required mechanical ven-
The initial surgical debridement was performed in the ICU.
Necrotic soft tissue, including the skin and fascia of the neck and
anterior chest wall, was excised (Fig. 2, left).
Although the right back region was weakened due to extensive
fat necrosis, there was no overlying erythema or skin necrosis
(Fig. 2, right). Necrotic soft tissue was removed through three ver-
tical incisions; these were irrigated with large amounts of normal
saline solution. There was no underlying muscle involvement.
D. Morioka (
) · K. Nakatani · S.Watanabe · Y. Shimizu
F. Ohkubo · Y. Hosaka
Department of Plastic and Reconstructive Surgery,
Showa University,1-5-8, Hatanodai, Shinigawa-ku,
Tokyo 142-8666, Japan
Eur J Plast Surg (1999) 22:264–266 © Springer-Verlag 1999
D. Morioka · K. Nakatani · S. Watanabe · Y. Shimizu
F. Ohkubo · Y. Hosaka
Cervical necrotizing fasciitis with upper trunk extension
Received: 16 September 1998 / Accepted: 11 November 1998
Fig. 1 A 49-year-old man with extensive skin necrosis from the
neck to the anterior chest wall