Csízy, István

Juhász, István

Kiss, Csongor

Remenyik, Éva

Szabó, Levente

Szegedi, István

Szikszay, Edit

Dermatologic Therapy

DEA University of Debrecen Electronic Archive

THERAPEUTIC HOTLINE2Excessive pediatric fasciitis3necrotisans due to Pseudomonas4aeruginosa infection successfully5treated with negative pressure6wound therapy7 Szabo LeventeAQ4 *, Istvan Szegedi*, Csongor Kiss*,8 Edit Szikszay*, Eva Remenyik†, Istvan Csızy*9 & Istvan JuhaszAQ2 †,‡10 *University of Debrecen Clinical Center, Institute of Pediatrics, Debrecen,11 Hungary, †University of Debrecen Clinical Center, Dept. Dermatology, Burn12 and Dermatosurgery Unit, Debrecen, Hungary and ‡University of Debrecen,13 Faculty of Dental Medicine, Dept. of Surgery and Operative Techniques,14 DebrecenAQ3 , Hungary15 ABSTRACT: The case of a 10-year old female child is described with a history of myeloproliferative16 disorder having skin, bone and visceral involvement. Bone marrow biopsy revealed histiocytosis X.17 During chemotherapy necrotizing fasciitis of the lower abdominal wall was diagnosed. Multiple18 microbiological cultures taken from the wound base revealed Pseudomonas aeruginosa infection.19 Surgical necrectomy and application of negative pressure wound therapy (NPWT) was started20 together with intensive care treatment for sepsis. As both wound and general condition of the patient21 improved, autologous split thickness skin grafting was carried out in two sitting under continuing22 NPWT application. The applied skin grafts showed excellent take, the perilesional subcutaneous23 recesses resolved and complete healing was achieved after 28 days of NPWT treatment. Proper24 dermatological diagnosis and immediate escharectomy complemented with application of NPWT25 can be life-saving in the treatment of necrotizing fasciitis.26 KEYWORDS: fasciitis necrotisans, histiocytosis X, life-saving, negative pressure wound therapy,27 pediatric case, Pseudomonas aeruginosa infection282930Introduction31Necrotizing fasciitis, a severe infectious condi-32tion associated with high mortality is relatively33rare in the pediatric population. ChildrenAQ6Address correspondence and reprint requests to: IstvanJuhasz MD PhD, Department of Dermatology, Clinical Center,University of Debrecen, Nagyerdei krt 98, H-4032, Debrecen,Hungary, or email: ijuhi@yahoo.com1Dermatologic Therapy, Vol. 00, 2015, 00–00DOI:10.1111/.12252VC 2015 Wiley Periodicals, Inc.DERMATOLOGIC THERAPYISSN1396-0296J_ID: DTH Customer A_ID: DTH12252 Cadmus Art: DTH12252 Ed. Ref. No.: DTH-15-0007.R1 Date: 2-May-15 Stage: Page: 1ID: Dimple.philip Time: 09:33 I Path: N:/3b2/DTH#/Vol00000/150046/APPFile/JW-DTH#15004634 suffering from oncohematological disorders,35 either due to their disease state or to the side36 effect of the applied therapy have a higher37 chance of developing severe or even life-38 threatening skin and soft tissue infections. These39 cases are associated with intense symptoms and40 rapid progression along deep structures like fas-41 ciae and connective tissue septae (1). In the42 majority of cases the infection is caused by gram43 positive bacteria or gram positive and anaerobic44 bacteria, whereas rarely its cause can be gram45 negative bacteria, such as P. aeruginosa. (2). It is46 very important to contain the rapidly progressing47 infection by extensive removal of the necrotic48 tissue without delay (3). Promoting wound heal-49 ing with the application of sub atmospheric50 pressure onto the wound bed is becoming more51 and more widespread not only in chronic52 wounds but also in acute conditions like burns,53 surgical site infection or fasciitis (4). This therapy54 while removes the excess wound fluid, dimin-55 ishes absorbance of toxic substances, promotes56 separation of nonvital tissue and it reduces bac-57 terial load of the treated area. It also effectively58 improves microcirculation and oxygenation of59 the necrobiotic layer of the wound thus promot-60ing regeneration (5). Even successful treatment61of fasciitis necrotisans is very often associated62with loss of the involved limb or other severe63mutilations (6).64Case report65A 10-year old female child had a history of mye-66loproliferative disorder with involvement of skin,67bone, and visceral organs. Bone marrow biopsy68revealed histiocytosis X. The pediatric oncology69team started combination chemotherapy accord-70ing to the German-Austrian Lymphoma working71group’s DAL HX 90 induction protocol. One72month later, during cytostatic therapy she devel-73oped fever with elevated CRP and PCT levels.74Despite empirically chosen parenteral antibiotic75therapy her general status deteriorated while an76inflammatory infiltrate was observed on the vul-77var skin on both sides. Incision and drainage78revealed no pus discharge, combined antibiotics79were installed and the perilesional redness80resided. Four days later together with general81septic signs a rapidly growing large violaceous-82grey phlegmonous infiltrate appeared on theCOLORFIG. 1.AQ5 •••.J_ID: DTH Customer A_ID: DTH12252 Cadmus Art: DTH12252 Ed. Ref. No.: DTH-15-0007.R1 Date: 2-May-15 Stage: Page: 2ID: Dimple.philip Time: 09:33 I Path: N:/3b2/DTH#/Vol00000/150046/APPFile/JW-DTH#150046283 skin of the lower abdomen. Dermatology consul-84 tation revealed the diagnosis of fasciitis necroti-85 sans. Extensive necrectomy of the skin of lower86 abdomen was carried out in general anesthesia87 with partial removal of the abdominal fascia.88 The separation of skin from abdominal wall89 could be followed almost up to the axillae on90 both sides of the torso (!). Negative pressure91 therapy (NPWT) was applied (V.A.C. ATS system92 device with Granufoam dressing, KCI San Anto-93 nio, TX) resulting in continuous drainage of thick94 purulent wound fluid, whose bacterial culture95 revealed P. aeruginosa infection. She was hospi-96 talized at the pediatric ICU while surgery and97 wound treatment was carried out by a team of98 pediatric and dermatologic surgeons. Under99 intensive care and carbopenem therapy the gen-100 eral condition of the patient improved. Four days101 later at dressing change the wound bed appeared102 mostly healthy and granulating. At nine days103 into vacuum therapy autologous split thickness104 skin grafting was carried out onto the abdominal105 muscle and remaining fascia and NPWT was106 reapplied with a silver-containing impregnated107 gauze layer under the foam dressing. The108 applied skin grafts showed excellent take, and109 the same procedure (skin grafting1NPWT) was110 applied again 11 days later to the edges of the111 wound, to cover the rim of exposed subcutane-112 ous fat. Parallel with epithelization the perile-113 sional subcutaneous recesses resolved and114 complete closure was achieved after 28 days of115 continuous NPWT treatment. Further protective116 dressings were applied for 10 more days while117 successful rehabilitation therapy resulted in full118 recovery. Fourteen days after discontinuation of119 NPWT she was released home.120 Discussion121 Septic complications are a frequent sequel of the122 more and more aggressive and successful thera-123 peutic regimes applied in the treatment of hem-124 atological disorders (2,7,8). Authors describe a125 case where the proper dermatological diagnosis126 played an important role in starting an aggres-127 sive complex therapy of necrotizing fasciitis. The128use of negative pressure devices has revolution-129ized wound treatment to a degree comparable to130the historic introduction of the moist WH con-131cept. Our case demonstrates the effective com-132bined use of negative pressure therapy and133aggressive debridement with antibiotic support134in a rare and rapidly deteriorating impending135condition. In this critically ill pediatric patient136with extensive necrotizing fasciitis, the effectivity137of the surgical removal of infected tissue and138wound coverage was greatly enhanced by the139continuous application of subatmospheric pres-140sure both before and after split thickness skin141grafting. This technique, most widely utilized in142the treatment of chronic wounds, is already143familiar to dermatologic surgeons. It was effec-144tively used in this case to remove toxins and145bacteria from the wound site thus complement-146ing pediatric surgical therapy and the combined147efforts led to the successful multidisciplinary148treatment of this potentially lethal condition.149References1501. Sarkar B, Napolitano LM. Necrotizing soft tissue infec-151tions. Minerva Chir 2010: 65 (3): 347–362.1522. Lo WT, Cheng SN, Wang C-C, et al. Extensive necrotising153fasciitis caused by Pseudomonas aeruginosa in a child154with acute myeloid leukaemia: case report and literature155review. Eur J Pediatr 2005; 164 (2): 113–114.1563. Endorf FW, Cancio LC, Klein MB. Necrotizing soft-tissue157infections: clinical guidelines. J Burn Care Res 2009; 30158(5): 769–775.1594. Steinstraesser L, Sand M, Steinau HU. Giant VAC in a160patient with extensive necrotizing fasciitis. Int J Low161Extrem Wounds 2009; 8 (1): 28–30.1625. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a163new method for wound control and treatment: clinical164experience. Ann Plast Surg 1997; 38 (6): 563–576.1656. Fs Al-Subhi, RM Zuker, WG Cole. Vacuum-assisted166closure as a surgical assistant in life-threatening necrotiz-167ing fasciitis in children. Can J Plast Surg 2010; 18 (4):168139–142.1697. Jaing TH, Huang CS, Chiu CH, et al. Surgical implications170of Pseudomonas aeruginosa necrotizing fasciitis in a child171with acute lymphoblastic leukemia. J Pediatr Surg 2001;17236: 948–50.1738. Melchionda F, Pession A. Negative pressure treatment for174necrotizing fasciitis after chemotherapy. Pediatr Rep 2011;1753 (4): e33. doi: 10.4081/pr.2011.e33.J_ID: DTH Customer A_ID: DTH12252 Cadmus Art: DTH12252 Ed. Ref. No.: DTH-15-0007.R1 Date: 2-May-15 Stage: Page: 3ID: Dimple.philip Time: 09:33 I Path: N:/3b2/DTH#/Vol00000/150046/APPFile/JW-DTH#150046Excessive pediatric fasciitis necrotisans3AUTHOR QUERY FORMDear Author,During the preparation of your manuscript for publication, the questions listed below have arisen. Please attend tothese matters and return this form with your proof.Many thanks for your assistance.QueryReferencesQuery RemarksAQ1 Please check whether the short title is OK as typeset.AQ2 Please provide the highest education qualification for all the authors and also check whether theauthor names are OK as typeset.AQ3 Please provide department/division name for affiliation “*” and also check whether the affiliations areOK as typeset.AQ4 Please confirm that given names (red) and surnames/family names (green) have been identifiedcorrectly.AQ5 Please provide citation and figure caption for Figure present in the manuscript.AQ6 Kindly check manuscript type.J_ID: DTH Customer A_ID: DTH12252 Cadmus Art: DTH12252 Ed. Ref. No.: DTH-15-0007.R1 Date: 2-May-15 Stage: Page: 4ID: Dimple.philip Time: 09:33 I Path: N:/3b2/DTH#/Vol00000/150046/APPFile/JW-DTH#150046

Excessive pediatric fasciitis necrotisans due to Pseudomonas aeruginosa infection successfully treated with negative pressure wound therapy

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Excessive pediatric fasciitis necrotisans due to Pseudomonas aeruginosa infection successfully treated with negative pressure wound therapy

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