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Necrotizing fasciitis and streptococcal toxic shock syndrome secondary to varicella in a healthy child.

Kwak BO, Lee MJ, Park HW, Song MK, Chung S, Kim KS - Korean J Pediatr (2014)

Bottom Line: Her skin lesions worsened, she became lethargic, and had episodes of hypotension and coagulopathy.She was diagnosed as necrotizing fasciitis and streptococcal toxic shock syndrome, and successfully treated with repeated surgical debridement and fasciotomy, in addition to intensive antibiotics.Early diagnosis and intensive treatment are required to prevent a fatal outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea.

ABSTRACT
Varicella is usually considered to be a benign disease in healthy children; however, serious complications can occur such as necrotizing fasciitis and toxic shock syndrome. We describe a 38-month-old girl with necrotizing fasciitis and streptococcal toxic shock syndrome following varicella. She was previously healthy and vaccinated against varicella at 12 months of age. She had been diagnosed with varicella three days prior to presenting at our facility; she developed fever, vomiting, and painful swelling on her left flank. Her skin lesions worsened, she became lethargic, and had episodes of hypotension and coagulopathy. Necrotizing fasciitis on the left abdominal wall, buttocks, and left thigh was diagnosed by magnetic resonance imaging, and group A Streptococcus was isolated from a tissue culture. She was diagnosed as necrotizing fasciitis and streptococcal toxic shock syndrome, and successfully treated with repeated surgical debridement and fasciotomy, in addition to intensive antibiotics. Our experience suggests that necrotizing fasciitis in patients with varicella should be considered to be a rare complication even with widespread vaccine use. Early diagnosis and intensive treatment are required to prevent a fatal outcome.

No MeSH data available.


Related in: MedlinePlus

Abdominal computed tomography (CT) scan of the patient. (A) At the time of admission, it showed extensive subcutaneous soft tissue swelling of the left anterior abdominal wall, flank, and inguinal area. (B) At the 3rd day of admission, follow-up abdominal CT scan showed an aggravated, extensive subcutaneous soft tissue swelling in the left anterior abdominal wall, both flanks, back, and inguinal area.
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Figure 2: Abdominal computed tomography (CT) scan of the patient. (A) At the time of admission, it showed extensive subcutaneous soft tissue swelling of the left anterior abdominal wall, flank, and inguinal area. (B) At the 3rd day of admission, follow-up abdominal CT scan showed an aggravated, extensive subcutaneous soft tissue swelling in the left anterior abdominal wall, both flanks, back, and inguinal area.

Mentions: A previously healthy 38-month-old girl visited the Emergency Department with fever, irritability, and a chief complaint of increasing pain and swelling in the left flank. She had been diagnosed with varicella at a local clinic three days ago, despite having been vaccinated against varicella. She had been vomiting for one day and developed fever, abdominal pain in the left lower quadrant, and painful swelling of the left flank. At the time of admission, body temperature was 38.9℃, pulse rate was 128 beats per minute, respiratory rate was 24 breaths per minute, and blood pressure was 92/50 mmHg. Ruptured blisters, a macular rash, including some lesions with painful purplish swelling, were noticed on the skin of her left flank extending to the buttocks (Fig. 1). Laboratory investigation showed a hemoglobin concentration of 11.7 g/dL, white blood cell count 5,250/µL (84% neutrophils, 8% lymphocytes, 1% monocytes), platelet count of 80,000/µL, and C-reactive protein of 17.21 mg/dL. VZV IgM and IgG were all positive. An abdominal computed tomography (CT) scan showed extensive subcutaneous soft tissue swelling of the left anterior abdominal wall, flank, and inguinal area (Fig. 2A). The patient was treated with hydration and intravenous antibiotics (ceftriaxone). However, the purplish swelling with macular rash lesion rapidly extended to the back and left thigh over the following two days; in addition, it exhibited necrotic change. She became lethargic and oliguric (0.7 mL/kg/hr). Her blood pressure decreased to 84/27 mmHg. Aggressive fluid therapy and transfusion were administered because she had episodes of hypotension. Laboratory investigation revealed disseminated intravascular coagulation (hemoglobin concentration, 8.6 g/dL; white blood cell count, 10,340/µL [62.1% neutrophils, 28.8% lymphocytes, 6.2% monocytes]; platelet count, 53,000/µL; prothrombin time, 15.3 seconds; partial thromboplastin time, 45.8 seconds; fibrinogen, 446 mg/dL; D-dimer, 3.94 µg/mL; and fibrin degradation products, 13.64 µg/mL). Follow-up abdominal CT scan showed an aggravated, extensive subcutaneous soft tissue swelling in the left anterior abdominal wall, both flanks, back, and inguinal area (Fig. 2B). Magnetic resonance imaging (MRI) was performed and it showed NF on left abdominal wall, buttocks, and left thigh (Fig. 3). In addition to intensive antibiotics (vancomycin and clindamycin) treatment, necrotic skin and soft tissue were removed after repeated surgical debridement, local dressing, and fasciotomy for three times. Group A Streptococcus (GAS) was isolated from the tissue culture, which was susceptible to penicillin and clindamycin, but no bacteria was isolated from the blood cultures. Antibiotics were changed to ampicillin/sulbactam and clindamycin. Isolation of GAS from tissue culture and the clinical signs such as hypotension, coagulopathy and soft tissue necrosis led to the diagnosis of streptococcal toxic shock syndrome. Antibiotics treatment and supportive care were continued. After five weeks the patient was discharged in good health and her skin lesions were healing.


Necrotizing fasciitis and streptococcal toxic shock syndrome secondary to varicella in a healthy child.

Kwak BO, Lee MJ, Park HW, Song MK, Chung S, Kim KS - Korean J Pediatr (2014)

Abdominal computed tomography (CT) scan of the patient. (A) At the time of admission, it showed extensive subcutaneous soft tissue swelling of the left anterior abdominal wall, flank, and inguinal area. (B) At the 3rd day of admission, follow-up abdominal CT scan showed an aggravated, extensive subcutaneous soft tissue swelling in the left anterior abdominal wall, both flanks, back, and inguinal area.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4316598&req=5

Figure 2: Abdominal computed tomography (CT) scan of the patient. (A) At the time of admission, it showed extensive subcutaneous soft tissue swelling of the left anterior abdominal wall, flank, and inguinal area. (B) At the 3rd day of admission, follow-up abdominal CT scan showed an aggravated, extensive subcutaneous soft tissue swelling in the left anterior abdominal wall, both flanks, back, and inguinal area.
Mentions: A previously healthy 38-month-old girl visited the Emergency Department with fever, irritability, and a chief complaint of increasing pain and swelling in the left flank. She had been diagnosed with varicella at a local clinic three days ago, despite having been vaccinated against varicella. She had been vomiting for one day and developed fever, abdominal pain in the left lower quadrant, and painful swelling of the left flank. At the time of admission, body temperature was 38.9℃, pulse rate was 128 beats per minute, respiratory rate was 24 breaths per minute, and blood pressure was 92/50 mmHg. Ruptured blisters, a macular rash, including some lesions with painful purplish swelling, were noticed on the skin of her left flank extending to the buttocks (Fig. 1). Laboratory investigation showed a hemoglobin concentration of 11.7 g/dL, white blood cell count 5,250/µL (84% neutrophils, 8% lymphocytes, 1% monocytes), platelet count of 80,000/µL, and C-reactive protein of 17.21 mg/dL. VZV IgM and IgG were all positive. An abdominal computed tomography (CT) scan showed extensive subcutaneous soft tissue swelling of the left anterior abdominal wall, flank, and inguinal area (Fig. 2A). The patient was treated with hydration and intravenous antibiotics (ceftriaxone). However, the purplish swelling with macular rash lesion rapidly extended to the back and left thigh over the following two days; in addition, it exhibited necrotic change. She became lethargic and oliguric (0.7 mL/kg/hr). Her blood pressure decreased to 84/27 mmHg. Aggressive fluid therapy and transfusion were administered because she had episodes of hypotension. Laboratory investigation revealed disseminated intravascular coagulation (hemoglobin concentration, 8.6 g/dL; white blood cell count, 10,340/µL [62.1% neutrophils, 28.8% lymphocytes, 6.2% monocytes]; platelet count, 53,000/µL; prothrombin time, 15.3 seconds; partial thromboplastin time, 45.8 seconds; fibrinogen, 446 mg/dL; D-dimer, 3.94 µg/mL; and fibrin degradation products, 13.64 µg/mL). Follow-up abdominal CT scan showed an aggravated, extensive subcutaneous soft tissue swelling in the left anterior abdominal wall, both flanks, back, and inguinal area (Fig. 2B). Magnetic resonance imaging (MRI) was performed and it showed NF on left abdominal wall, buttocks, and left thigh (Fig. 3). In addition to intensive antibiotics (vancomycin and clindamycin) treatment, necrotic skin and soft tissue were removed after repeated surgical debridement, local dressing, and fasciotomy for three times. Group A Streptococcus (GAS) was isolated from the tissue culture, which was susceptible to penicillin and clindamycin, but no bacteria was isolated from the blood cultures. Antibiotics were changed to ampicillin/sulbactam and clindamycin. Isolation of GAS from tissue culture and the clinical signs such as hypotension, coagulopathy and soft tissue necrosis led to the diagnosis of streptococcal toxic shock syndrome. Antibiotics treatment and supportive care were continued. After five weeks the patient was discharged in good health and her skin lesions were healing.

Bottom Line: Her skin lesions worsened, she became lethargic, and had episodes of hypotension and coagulopathy.She was diagnosed as necrotizing fasciitis and streptococcal toxic shock syndrome, and successfully treated with repeated surgical debridement and fasciotomy, in addition to intensive antibiotics.Early diagnosis and intensive treatment are required to prevent a fatal outcome.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea.

ABSTRACT
Varicella is usually considered to be a benign disease in healthy children; however, serious complications can occur such as necrotizing fasciitis and toxic shock syndrome. We describe a 38-month-old girl with necrotizing fasciitis and streptococcal toxic shock syndrome following varicella. She was previously healthy and vaccinated against varicella at 12 months of age. She had been diagnosed with varicella three days prior to presenting at our facility; she developed fever, vomiting, and painful swelling on her left flank. Her skin lesions worsened, she became lethargic, and had episodes of hypotension and coagulopathy. Necrotizing fasciitis on the left abdominal wall, buttocks, and left thigh was diagnosed by magnetic resonance imaging, and group A Streptococcus was isolated from a tissue culture. She was diagnosed as necrotizing fasciitis and streptococcal toxic shock syndrome, and successfully treated with repeated surgical debridement and fasciotomy, in addition to intensive antibiotics. Our experience suggests that necrotizing fasciitis in patients with varicella should be considered to be a rare complication even with widespread vaccine use. Early diagnosis and intensive treatment are required to prevent a fatal outcome.

No MeSH data available.


Related in: MedlinePlus