American Journal of Infection Control 43 (2015) 404-5
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Necrotizing fasciitis in patients with head and neck cancer Akshat Malik MS *, Swagnik Chakrabarty MS, Sudhir Nair MS, Deepa Nair MS, Pankaj Chaturvedi MS Department of Head and Neck Oncology, Tata Memorial Hospital, Parel, Mumbai, India
Key Words: Surgical site infections Infections in malignancy
Necrotizing fasciitis is a severe polybacterial infection characterized by necrosis of the fascia and adjacent soft tissues with rapid expansion of the infection along the fascial planes. It is a rare and potentially fatal entity in the head and neck region. We present 2 patients with head and neck cancers who developed necrotizing fasciitis during the postoperative period. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Necrotizing fasciitis is a severe polybacterial infection characterized by necrosis of the fascia and adjacent soft tissues with rapid expansion of the infection along the fascial planes. It is a rare and potentially fatal entity in the head and neck region. We present 2 cases of patients with head and neck cancer who developed necrotizing fasciitis during the postoperative period. These were approved by our institutional ethics and review board.
CASE REPORT Case 1 A 59-year old man with carcinoma hypopharynx underwent total laryngectomy with partial pharyngectomy and bilateral selective neck dissection. Reconstruction was done using a patch pectoralis major myocutaneous flap (PMMC). On the third postoperative day, the patient had 2 bouts of vomiting following which he developed dehiscence and leak through the tracheostomal sutures. The tracheostomal sutures were opened and wound wash given. Thereafter he was started on cefoperazone-sulbactam via injection. By the next day he had developed multiple necrotic patches over the neck and anterior chest wall, the largest of which was about 6 4 cm in the left infraclavicular region. Wound swab was sent for culture and sensitivity testing and the patches were radically debrided. Two days later, the patient had bleeding from the left internal jugular
* Address correspondence to Akshat Malik, MS, Department of Head and Neck Oncology, Tata Memorial Hospital, Parel, Mumbai 400012, India. E-mail address: [email protected] (A. Malik). Conflicts of interest: None to report.
vein probably secondary to the pharyngeal salivary pharyngeal leak and infection. The internal jugular vein was ligated and pharyngeal wall leak was repaired. Necrotic patches were debrided again. The culture grew Klebsiella pneumonia and Pseudomonas aeruginosa, which were sensitive to tigecycline, meropenem, imipenem, and colistin. Additionally, a skin specimen showed heavy growth of Acinetobacter baumannii that was sensitive to only colistin and polymyxin. The patient was started on colistin and meropenem. On the ninth day, he developed breathlessness, drowsiness, hypotension, and fall in oxygen saturation. He was put on ventillatory support and vasopressors. His white blood cell counts increased to w 14,000/cu mm; however, blood and urine culture did not reveal any growth. He progressed into septic shock, developed multiorgan dysfunction, and died on 20th postoperative day. Case 2 A 42-year old man with carcinoma of the buccal mucosa underwent composite resection of buccal mucosa with hemimandibulectomy and neck dissection. Reconstruction was done using bipaddle PMMC. On the second postoperative day he developed necrosis of the outer skin paddle of PMMC, as well as part of the infraclavicular skin. Necrotic tissue was debrided. Underlying muscle was found to be healthy. Wound swab culture showed heavy growth of P aeruginosa sensitive to amikacin, gentamycin, cefoperazone, sulbactam, and ciprofloxacin. Injections of cefoperazone-sulbactam were started, apart from regular wound care. Gradually, the wound started granulating and by day 16 it had healed well enough for skin grafting to be done. However, the adjuvant therapy; that is, radiotherapy, had to be deferred due to delayed wound healing.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.01.010
A. Malik et al. / American Journal of Infection Control 43 (2015) 404-5
DISCUSSION Necrotizing fasciitis is a severe polybacterial infection associated with fascia and adjacent soft tissue necrosis with rapid expansion along the fascial planes. It is often associated with systemic toxicity and can, at times, be fatal.1 Necrotizing fasciitis can occur as a complication of various events, including surgical procedures, medical conditions, and things as trivial as a pin prick or insect bite. In the head and neck region, it can occur following mandibular fractures and abscesses. Patients having preexisting conditions like liver dysfunction, chronic renal failure, or thrombocytopenia have a poorer prognosis.2 It is seen less often in the head and neck region, and reports of it in head and neck cancers are scarce.3 It has rarely been seen to occur following multimodality treatment for head and neck cancers.4,5 There has been just a single case report of a fatal necrotizing fasciitis occurring in a patient who underwent laryngectomy. Ours is the second such case to be reported in literature.6 Three types of infections are described: Type I is polybacterial and commonly seen following surgical trauma, Type II is related to group A hemolytic streptococci, and Type III is associated with Clostridium and gas gangrene. Organisms commonly responsible are group A hemolytic streptococci, Staphylococcus aureus (including methicillin-resistant S aureus), Bacteroides, Clostridium, Pseudomonas, Proteus, and Klebsiella.2 It can be caused by aerobic or nonaerobic organisms. Fungal agents have also been held responsible.7 Molecular studies like genomic sequencing are often conducted to assess the evolution of multidrug-resistant strains and to look for ways to combat them. A recent study8 has shown “wild-type mtsR function” is required for group A Streptococcus to cause necrotizing fasciitis in mice and nonhuman primates and any mutation in it will reduce the infective and necrotizing capacity of the organism. Chromosomal recombination events are known to contribute to the genetic plasticity and ultimate success of many bacterial pathogens, like carbepenem-resistant K pneumonia.9 Early diagnosis is important for the proper treatment of necrotizing fasciitis.10 There should be a high index of suspicion. Erythema and induration of the overlying skin may be present. Pain may extend well beyond the erythematous region because the subfascial infection may extend beyond the area of apparent skin involvement. Pain may even be absent if nerve endings are involved. Radical debridement, regular wound care, and intravenous antibiotics form the mainstay of treatment. Mortality has been
405
variably reported from 20%-80% depending upon the site and time taken for treatment to start.10,11 Prognosis is poor for older patients (aged >50 years) and those with associated comorbidities (as seen in our first case). Death commonly occurs due to respiratory failure, renal failure, and multiorgan dysfunction.12 Prevention of these infections holds prime importance. This is because their cause is often not known and is generally deduced retrospectively. Therefore, all efforts must be made to prevent them. These include good preoperative surgical site preparation, judicious use of perioperative antibiotics, and prompt infection control measures. Our aim in presenting these cases is to reinforce the fact that necrotizing fasciitis is a grave condition that may result in fatal complications and systemic toxicity. Despite good infection control measures, if infection sets in then a high index of suspicion is essential for early diagnosis and prevention of spread of disease. Radical surgical debridement and antibiotics are important in the management of this disease.
References 1. Seijas Rosales T, Díaz Alcover C, Pérez Garrigues T. Necrotizing fasciitis of the head and neck. Report of 4 cases of cervical necrotizing fasciitis. Acta Otorrinolaringol Esp 1997;48:504-8. 2. Lee CY, Kuo LT, Peng KT, Hsu WH, Huang TW, Chou YC. Prognostic factors and monomicrobial necrotizing fasciitis: gram-positive versus gram-negative pathogens. BMC Infect Dis 2011;11:5. 3. Djupesland PG. Necrotizing fascitis of the head and neckereport of three cases and review of the literature. Acta Otolaryngol Suppl 2000;543:186-9. 4. Maluf FC, William WN Jr, Rigato O, Menon AD, Parise O Jr, Docema MF. Necrotizing fasciitis as a late complication of multimodal treatment for locally advanced head and neck cancer: a case report. Head Neck 2007;29:700-4. 5. Kelesidis T, Tsiodras S. Postirradiation Klebsiella pneumoniae-associated necrotizing fasciitis in the western hemisphere: a rare but life-threatening clinical entity. Am J Med Sci 2009;338:217-24. 6. Beerens AJ, Strack van Schijndel RJ, Mahieu HF, Leemans CR. Cervical necrotizing fasciitis with thoracic extension after total laryngectomy. J Laryngol Otol 2002;116:639-41. 7. Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a deadly infection. J Eur Acad Dermatol Venereol 2006;20:365-9. 8. Olsen RJ, Sitkiewicz I, Ayeras AA, Gonulal VE, Cantu C, Beres SB, et al. Decreased necrotizing fasciitis capacity caused by a single nucleotide mutation that alters a multiple gene virulence axis. Proc Natl Acad Sci U S A 2010;107:888-93. 9. DeLeo FR, Chen L, Porcella SF, Martens CA, Kobayashi SD, Porter AR, et al. Molecular dissection of the evolution of carbapenem-resistant multilocus sequence type 258 Klebsiella pneumonia. Proc Natl Acad Sci U S A 2014;111: 4988-93. 10. Rouse TM, Malangoni MA, Schulte WJ. Necrotizing fasciitis: a preventable disaster. Surgery 1982;92:765-70. 11. McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558-63. discussion 563-5. 12. Sadasivan J, Maroju NK, Balasubramaniam A. Necrotizing fasciitis. Indian J Plast Surg 2013;46:472-8.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Necrotizing fasciitis in patients with head and neck cancer Akshat Malik MS *, Swagnik Chakrabarty MS, Sudhir Nair MS, Deepa Nair MS, Pankaj Chaturvedi MS Department of Head and Neck Oncology, Tata Memorial Hospital, Parel, Mumbai, India
Key Words: Surgical site infections Infections in malignancy
Necrotizing fasciitis is a severe polybacterial infection characterized by necrosis of the fascia and adjacent soft tissues with rapid expansion of the infection along the fascial planes. It is a rare and potentially fatal entity in the head and neck region. We present 2 patients with head and neck cancers who developed necrotizing fasciitis during the postoperative period. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Necrotizing fasciitis is a severe polybacterial infection characterized by necrosis of the fascia and adjacent soft tissues with rapid expansion of the infection along the fascial planes. It is a rare and potentially fatal entity in the head and neck region. We present 2 cases of patients with head and neck cancer who developed necrotizing fasciitis during the postoperative period. These were approved by our institutional ethics and review board.
CASE REPORT Case 1 A 59-year old man with carcinoma hypopharynx underwent total laryngectomy with partial pharyngectomy and bilateral selective neck dissection. Reconstruction was done using a patch pectoralis major myocutaneous flap (PMMC). On the third postoperative day, the patient had 2 bouts of vomiting following which he developed dehiscence and leak through the tracheostomal sutures. The tracheostomal sutures were opened and wound wash given. Thereafter he was started on cefoperazone-sulbactam via injection. By the next day he had developed multiple necrotic patches over the neck and anterior chest wall, the largest of which was about 6 4 cm in the left infraclavicular region. Wound swab was sent for culture and sensitivity testing and the patches were radically debrided. Two days later, the patient had bleeding from the left internal jugular
* Address correspondence to Akshat Malik, MS, Department of Head and Neck Oncology, Tata Memorial Hospital, Parel, Mumbai 400012, India. E-mail address: [email protected] (A. Malik). Conflicts of interest: None to report.
vein probably secondary to the pharyngeal salivary pharyngeal leak and infection. The internal jugular vein was ligated and pharyngeal wall leak was repaired. Necrotic patches were debrided again. The culture grew Klebsiella pneumonia and Pseudomonas aeruginosa, which were sensitive to tigecycline, meropenem, imipenem, and colistin. Additionally, a skin specimen showed heavy growth of Acinetobacter baumannii that was sensitive to only colistin and polymyxin. The patient was started on colistin and meropenem. On the ninth day, he developed breathlessness, drowsiness, hypotension, and fall in oxygen saturation. He was put on ventillatory support and vasopressors. His white blood cell counts increased to w 14,000/cu mm; however, blood and urine culture did not reveal any growth. He progressed into septic shock, developed multiorgan dysfunction, and died on 20th postoperative day. Case 2 A 42-year old man with carcinoma of the buccal mucosa underwent composite resection of buccal mucosa with hemimandibulectomy and neck dissection. Reconstruction was done using bipaddle PMMC. On the second postoperative day he developed necrosis of the outer skin paddle of PMMC, as well as part of the infraclavicular skin. Necrotic tissue was debrided. Underlying muscle was found to be healthy. Wound swab culture showed heavy growth of P aeruginosa sensitive to amikacin, gentamycin, cefoperazone, sulbactam, and ciprofloxacin. Injections of cefoperazone-sulbactam were started, apart from regular wound care. Gradually, the wound started granulating and by day 16 it had healed well enough for skin grafting to be done. However, the adjuvant therapy; that is, radiotherapy, had to be deferred due to delayed wound healing.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.01.010
A. Malik et al. / American Journal of Infection Control 43 (2015) 404-5
DISCUSSION Necrotizing fasciitis is a severe polybacterial infection associated with fascia and adjacent soft tissue necrosis with rapid expansion along the fascial planes. It is often associated with systemic toxicity and can, at times, be fatal.1 Necrotizing fasciitis can occur as a complication of various events, including surgical procedures, medical conditions, and things as trivial as a pin prick or insect bite. In the head and neck region, it can occur following mandibular fractures and abscesses. Patients having preexisting conditions like liver dysfunction, chronic renal failure, or thrombocytopenia have a poorer prognosis.2 It is seen less often in the head and neck region, and reports of it in head and neck cancers are scarce.3 It has rarely been seen to occur following multimodality treatment for head and neck cancers.4,5 There has been just a single case report of a fatal necrotizing fasciitis occurring in a patient who underwent laryngectomy. Ours is the second such case to be reported in literature.6 Three types of infections are described: Type I is polybacterial and commonly seen following surgical trauma, Type II is related to group A hemolytic streptococci, and Type III is associated with Clostridium and gas gangrene. Organisms commonly responsible are group A hemolytic streptococci, Staphylococcus aureus (including methicillin-resistant S aureus), Bacteroides, Clostridium, Pseudomonas, Proteus, and Klebsiella.2 It can be caused by aerobic or nonaerobic organisms. Fungal agents have also been held responsible.7 Molecular studies like genomic sequencing are often conducted to assess the evolution of multidrug-resistant strains and to look for ways to combat them. A recent study8 has shown “wild-type mtsR function” is required for group A Streptococcus to cause necrotizing fasciitis in mice and nonhuman primates and any mutation in it will reduce the infective and necrotizing capacity of the organism. Chromosomal recombination events are known to contribute to the genetic plasticity and ultimate success of many bacterial pathogens, like carbepenem-resistant K pneumonia.9 Early diagnosis is important for the proper treatment of necrotizing fasciitis.10 There should be a high index of suspicion. Erythema and induration of the overlying skin may be present. Pain may extend well beyond the erythematous region because the subfascial infection may extend beyond the area of apparent skin involvement. Pain may even be absent if nerve endings are involved. Radical debridement, regular wound care, and intravenous antibiotics form the mainstay of treatment. Mortality has been
405
variably reported from 20%-80% depending upon the site and time taken for treatment to start.10,11 Prognosis is poor for older patients (aged >50 years) and those with associated comorbidities (as seen in our first case). Death commonly occurs due to respiratory failure, renal failure, and multiorgan dysfunction.12 Prevention of these infections holds prime importance. This is because their cause is often not known and is generally deduced retrospectively. Therefore, all efforts must be made to prevent them. These include good preoperative surgical site preparation, judicious use of perioperative antibiotics, and prompt infection control measures. Our aim in presenting these cases is to reinforce the fact that necrotizing fasciitis is a grave condition that may result in fatal complications and systemic toxicity. Despite good infection control measures, if infection sets in then a high index of suspicion is essential for early diagnosis and prevention of spread of disease. Radical surgical debridement and antibiotics are important in the management of this disease.
References 1. Seijas Rosales T, Díaz Alcover C, Pérez Garrigues T. Necrotizing fasciitis of the head and neck. Report of 4 cases of cervical necrotizing fasciitis. Acta Otorrinolaringol Esp 1997;48:504-8. 2. Lee CY, Kuo LT, Peng KT, Hsu WH, Huang TW, Chou YC. Prognostic factors and monomicrobial necrotizing fasciitis: gram-positive versus gram-negative pathogens. BMC Infect Dis 2011;11:5. 3. Djupesland PG. Necrotizing fascitis of the head and neckereport of three cases and review of the literature. Acta Otolaryngol Suppl 2000;543:186-9. 4. Maluf FC, William WN Jr, Rigato O, Menon AD, Parise O Jr, Docema MF. Necrotizing fasciitis as a late complication of multimodal treatment for locally advanced head and neck cancer: a case report. Head Neck 2007;29:700-4. 5. Kelesidis T, Tsiodras S. Postirradiation Klebsiella pneumoniae-associated necrotizing fasciitis in the western hemisphere: a rare but life-threatening clinical entity. Am J Med Sci 2009;338:217-24. 6. Beerens AJ, Strack van Schijndel RJ, Mahieu HF, Leemans CR. Cervical necrotizing fasciitis with thoracic extension after total laryngectomy. J Laryngol Otol 2002;116:639-41. 7. Kihiczak GG, Schwartz RA, Kapila R. Necrotizing fasciitis: a deadly infection. J Eur Acad Dermatol Venereol 2006;20:365-9. 8. Olsen RJ, Sitkiewicz I, Ayeras AA, Gonulal VE, Cantu C, Beres SB, et al. Decreased necrotizing fasciitis capacity caused by a single nucleotide mutation that alters a multiple gene virulence axis. Proc Natl Acad Sci U S A 2010;107:888-93. 9. DeLeo FR, Chen L, Porcella SF, Martens CA, Kobayashi SD, Porter AR, et al. Molecular dissection of the evolution of carbapenem-resistant multilocus sequence type 258 Klebsiella pneumonia. Proc Natl Acad Sci U S A 2014;111: 4988-93. 10. Rouse TM, Malangoni MA, Schulte WJ. Necrotizing fasciitis: a preventable disaster. Surgery 1982;92:765-70. 11. McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558-63. discussion 563-5. 12. Sadasivan J, Maroju NK, Balasubramaniam A. Necrotizing fasciitis. Indian J Plast Surg 2013;46:472-8.
