Bilateral Periorbital Necrotizing Fasciitis
2004; American Medical Association; Volume: 140; Issue: 6 Linguagem: Inglês
10.1001/archderm.140.6.664
ISSN1538-3652
Autores Tópico(s)Otolaryngology and Infectious Diseases
ResumoA 76-year-old white woman presented with a history of emphysema, congestive heart failure, and rheumatoid arthritis. She had previously been treated with steroid inhalers for her lung disease and with nonsteroidal agents for her arthritis. She had no history of systemic immunosuppressive therapy, except for a single dose of methotrexate that she had taken the week before presentation. She developed symptoms of bilateral eyelid redness and weeping the evening before admission and experienced general malaise with shaking chills and vomiting throughout the night. On waking the next morning, her eyelids were swollen and appeared bruised. She sought evaluation at her local hospital’s emergency department. Her eyelids progressively worsened, developing more pronounced discoloration and a bullous appearance. She was transferred to our medical center for further evaluation. On arrival to the emergency department, she was in a state of disseminated intravascular coagulation. Because she was hypotensive and in respiratory distress, pressure and ventilatory support were administered. She was admitted to the intensive care unit, and the plastic surgery admitting team consulted both dermatology and ophthalmology. On examination, she had bilateral, well-demarcated, blue-black necrotic plaques surrounding her eyes on both upper and lower eyelids (Figure 1). She had large, serosanguineous, fluid-filled bullae at the border of these plaques (Figure 2). The results of the rest of the cutaneous examination were normal, except for warmth of the right knee at the site of a well-healed surgical scar. Laboratory test results at admission were significant for a white blood cell count of 1.5 10/μL, with a left shift of 22% band cells and 52% segmented cells; a hemoglobin level of 10.0 g/dL; a hematocrit of 31%; and a platelet count of 60 10/ μL. A computed tomographic scan of the head showed pansinusitis with left preorbital and left subcutaneous facial swelling. Biopsy specimens from the right upper eyelid showed necrosis of the dermis and subcutaneous tissue with acute inflammation, vascular thrombosis, hemorrhage, bacteria, and cellular debris (Figure 3). Tissue and blood cultures were positive for group A -hemolytic streptococci. Because of the clinical presentation, bacterial culture results, and histopathologic findings in this case, the patient was diagnosed as having necrotizing fasciitis (NF). Her primary team decided on medical therapy rather than more aggressive surgical debridement because she was considered to be a high-risk surgical candidate and because the necrotic areas appeared to be clinically stable. She was empirically started on a regimen of ceftriaxone sodium (Rocephin), vancomycin hydrochloride, and metronizadole, and her therapy was subsequently changed to penicillin G and clindamycin hydrochloride. The only surgical intervention for her NF was bedside debridement of the periorbital necrotic tissue, which was performed by an oculoplastic surgeon. Her NF appeared to have stabilized, yet her hospitalization was complicated by other factors. During her hospital course, she had acute renal failure that required dialysis, atrial fibrillation, Pseudomas aeruginosa pneumonia, bleeding in the gastrointestinal tract caused by a duodenal ulcer, and septic arthritis of the right knee, of unknown etiology, which required repeated aspiration. After a month of hospitalization, she continued to require ventilatory support and therapeutic interventions to evaluate and treat her compounding illnesses. Her family decided to withdraw support and she died soon afterward. Postmortem examination revealed that her death was the result of a complicated pattern of local and systemic infection. The primary cause of death was listed as gram-negative septicemia due to bronchopneumonia.
Referência(s)