Nigerian Journal of Paediatrics 2011;38(3):142 -145
CASE REPORT
Ibekwe MU,
Unusual
presentation
of
necrotizing
Ojukwu J O
Ibekwe RC
fasciitis in an HIV exposed infant: A Case
Report.
Received: 23rd May 2011
Abstract Necrotizing
unique combination of absence of
Accepted: 23rd July 2011
fasciitis(NF) is a potentially life
known pre existing cause, unusual
threatening soft tissue infection
site of presentation of NF, in this
Ibekwe MU
( )
characterized by rapidly
instance, it presented on the scalp,
Ojukwu J O
spreading inflammation with
in an HIV exposed neonate. It also
Department of Paediatrics Ebonyi
necrosis of fascia, subcutaneous
stressed the importance prompt
State University Teaching
tissues and overlying skin and is
diagnosis of all skin lesions in
Hospital Abakaliki Nigeria.
associated with signs of systemic
HIV exposed neonates, and the
Email:
toxicity.
role of early diagnosis and
ugochiamadife@yahoo.com
We present a case report of an
aggressive multi disciplinary team
uncommon presentation of NF in
management in salvaging NF
Ibekwe RC
an HIV exposed infant.
which is a potentially fatal
Department of Paediatrics,
This report is highlighting the
condition.
University of Nigeria Enugu
Nigeria.
Introduction
University Teaching Hospital Abakaliki (EBSUTH)
with 2 weeks history of scalp ulcer. She was aged 3
Necrotizing fasciitis(NF) is
a
potentially life
weeks and weighed 3.4kg. She was delivered at term
threatening
soft tissue infection characterized by
to
a
27year
old
multiparous
woman
who
had
rapidly spreading inflammation with necrosis of
antenatal care in a rural maternity home but was
fascia, subcutaneous tissues and overlying skin and
neither counselled nor tested for HIV. Delivery was at
is associated with signs of systemic toxicity
1-3
NF is
a maternity home though uneventful, mother had
predominantly
an
adult
disorder
and
is
more
prolonged rapture of membranes of 4 days associated
commonly
reported
in
adults
with
preexisting
with high grade fever. Immediate postnatal condition
medical disorder such as diabetes mellitus and those
of baby was uneventful and she was exclusively
with compromised immunity
2-5
. In the neonates it is a
breastfed.
rare
condition
and
often
times
attributable
to
omphalitis,
balanitis,
At 4 day of life, vesicular lesions appeared posterior
th
secondary
infection
of
mammitis, postoperative complication of surgery
to the left ear of the baby which rapidly progressed in
and fetal monitoring.
1,4-7
the next few days to involve most parts of the
posterior scalp. By the 8
th
day, the scalp lesions
This report is highlighting the unique combination
ruptured
and
became
ulcerated
discharging
of absence of known pre existing cause, unusual site
serosanguinous fluid. This was associated with high
of presentation and HIV exposure in a neonate with
grade fever, poor feeding and lethargy. There was no
NF, and also stresses the role of early diagnosis and
history of trauma or surgical procedure preceding the
aggressive multidisciplinary team management in
appearance of the scalp lesions. Initially ampicillin
salvaging this potentially fatal condition.
cream was applied to the lesion and oral ampiclox
suspension was given.
The symptoms however
UC was a female infant admitted through the
worsened and the mother presented the child to a local
children's emergency room of Ebonyi State
hospital in her community where she was
143
managed as a case of cellulitis.
By the 15
th
day of
Cefotaxime and augumentin. Swab culture from the
onset of the lesion, the baby's condition deteriorated
scalp lesion yielded (a) B-Haemolytic Streptococcus
and
she
was
referred
to
EBSUTH
for
expert
that was sensitive to ciprofloxacin, septrin, and
management.
augumentin but resistant to Ampiclox, erythromycin,
ceftriaxone, and gentamicin. (b) Klebsiella spp that
On admission she was acutely ill looking
but
was sensitive to ciprofloxacin,ceftriaxone,oflaxacin
conscious,
febrile,
with
a
maximum
axillary
a n d
c e f a t o x i m e
b u t
r e s i s t a n t
t o
temperature of 38.9 C. She appeared mildly pale but
o
augumentin,gentamycin and septrin.
not dehydrated. She had a heart rate of140 beats/min
Human immunodeficiency virus (HIV) test was
and respiratory rate of 80 breaths/min. There was an
positive for the mother; however the baby's HIV
extensive ulcer over the posterior half of the scalp
status could not be confirmed due to lack of facility
and neck (fig 1, 2) which extended over the parietal
for PCR in our center.
and occipital areas of the scalp and posterior aspects
of the neck.
Within 24 hours of presentation, the surgical team
was invited and subsequently the baby was taken to
the theatre for wound debridement.
All the non
viable tissues were debrided until wound edges bled
freely. The wound was later covered with sufra-tule
and dressed on a daily basis
The antibiotics were later changed accordingly to
ciprofloxacin, and baby responded favourably after a
3 weeks course on antibiotics.
By the 2nd week
following admission granulation tissue was noticed,
however this did not completely cover the exposed
occipital bone. Plans were made for wound
resurfacing by the plastic surgeons, but this was
Figure 1
however not done because the family could not bear
the financial burden of plastic surgery. The child was
discharged home after 31 days of hospital stay and
was commenced on cotrimoxazole for pneumocystic
carini pneumonia (PCP) prophylaxis. She was
subsequently lost to follow up and plastic surgery
could not be done.
Discussion
Neonatal fasciitis (NF) is an uncommon but often
Figure 2
fatal bacterial infection of the skin, subcutaneous
tissue and fascia.
1,4-7
However Legbo
8,9
in his
There was destruction of skin, subcutaneous fascia
experience with 32 cases of childhood NF, reported
and muscle tissues leading to complete loss of
that NF may not be uncommon among neonates in
posterior scalp exposing the occipital bone with
North western Nigeria and is associated with
purulent exudation (fig1, 2). The total body surface
significant mortality and morbidity.
Most studies
area involved was estimated at 9.5%. The full blood
report that NF
is usually initiated following
count revealed a packed cell volume of 30% (37-
omphalitis, mammitis, balanitis fetalscalp
49%), a white cell count of 24.1x10 /l (4-11x10 /l).A
9
9
m o n i t o r i n g ,
n e c r o t i s i n g
e n t e r o c o l i t i s ,
Immunodeficiency and bullous impetigo
4,5,10
peripheral blood film revealed a shift to the left with
. It rarely
starts de novo.
4,5
toxic granulations of neutrophils. A diagnosis of NF
This index case contrasts these
with overwhelming neonatal sepsis was made and
reports as the child was in apparent good health at
the baby was commenced empirically on ceftriaxone
birth with no obvious predisposing factor following
and gentamycin.
the appearance of the scalp lesion While it is possible
that this case might be due to primary NF
5
(which
implies absence of any known cause) which is rare.
5
Blood Culture yielded Staphylococcus aureus that
was sensitive to ciprofloxacin, ceftriaxone and
gentamycin but resistant to septrin, ampiclox,
It is also possible that seemingly insignificant trauma
144
Breaching the delicate skin and leading to virulent
Early diagnosis
and prompt surgical debridement
bacterial invasion.
with appropriate antibiotics
are important
in
improving the chances of survival in patients with
NF.
5,6,8,10,17
It could be assumed perhaps because of earlier
It has been reported that patients with NF
have mortality rate of 73 % if left untreated
1,5
exposure of this infant to the mother who is HIV
and
positive may have resulted in her being infected with
without
surgery and medical assistance such as
the virus, thereby leading to
immunodeficiency.
antibiotics, the infection will rapidly progress and
HIV is the leading cause of childhood
will eventually lead to death. In this case however, the
immunodeficiency in Nigeria . Although the role of
11
child presented late to the hospital.
immunodeficiency as a contributing factor in NF has
been previously documented, this has been in the
This is probably due to previously reported poor
context of chicken pox , measles and acute
health seeking behavior of people living in remote
lymphoblastic leukaemia .
5,12-14
This is to our
villages in Nigeria, which is a consequence of
knowledge the first report linking a case of HIV
ignorance and poverty.
20
Despite this, she still
exposure in a neonate with NF .
survived, and could be attributed to the aggressive
and multidisciplinary management given her even in
The site of presentation of NF in this patient is
a resource poor setting such as ours.
unusual. While earlier reports noted the commonest
sites of presentation as the
abdominal wall
Skin resurfacing was not done and the child was lost
4,5,7
followed by the thorax and back
reports on scalp
to follow up. This is in spite of the fact that the HIV
presentation are few and commonly follows fetal
status of the mother was made known to her and she
scalp monitoring, which this child never had.
5,7
was counselled on its consequence on the child and
the availability of appropriate management of the
The diagnosis in this case was clinical. There was
condition. Due to poverty and ignorance discharge
extensive necrosis of skin subcutaneaous, facial and
against medical advice and default from follow up is a
muscle tissue extending from the parietal region to
major problem in this health facility and has been
previously reported.
20
the occiput and the back of the neck. NF typically
spreads along fascial planes causing widespread
thrombosis of vessels
1-5,7
in face of the seemingly
This communication is highlighting the association
weak defence mechanism of this child. It is not
between Neonatal NF and HIV infection, while
surprising that there was extensive involvement of
advocating an aggressive management of all skin
the scalp and apparent destruction of facsia and
lesions in HIV exposed neonates in order to avoid this
muscle, exposing the occipital bone. This is typically
potentially fatal condition.
We advocate for
the nature of NF and has been described as a flesh
improved maternal services to reach the unreached
eating bacteria syndrome
3,5,15
. This is because the
who are mostly in rural areas .There is need for proper
virulent causative bacteria release toxins capable of
HIV counseling in these remote areas and also
activating T cell non specifically. As a consequence
improving the prevention of mother- to- child
this causes overproduction of cytokines and severe
transmission (PMTCT) in our fight in curbing the
systemic illness
1,3,5,15,16
, which manifested in this child
menace of HIV/AIDS.
with fever, tachycardia, tachpnea, anemia,
leukoctocysis and toxic granulated neutrophils.
Neonatal NF is very rare and there is a need for high
Several diagnostic procedures had been advocated
index of suspicion in making prompt diagnosis, also
for use in early diagnosis of NF including
special attention should be paid to these infants who
ultrasound, CT scan, histology and MRI.
17-19
MRI
are exposed to HIV that are apparently increasing in
had been noted as the best tool in early diagnosis of
the Nigerian population . The authors also stressed
NF; it was not used here because of its unavailability.
that aggressive antibiotics and surgical debridement
18,19
However, the manifestation of NF in this case
could yield favourable results, while highlighting all
was typical thus making clinical diagnosis
the constraints to optimal care of this child.
unequivocal.
Blood culture yielded staphylococcus aureus while
wound culture yielded B-Haemolytic streptococcus
and klebsiella spp . This is in keeping with literature
Acknowledgement
reports
2-4,7-10
,
as the usual causative organisms,
although cultures sometimes are polymicrobial
2-4,7- 10
The authors are grateful to Dr Chinedu Nwigwe,
consultant general surgeon EBSUTH Abakaliki for
reviewing this article.
145
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