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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