Grand Rounds: “It’s Just a Flesh Wound”

1. Kevin T Lowder, MD – PGY2 02/16/2018 Grand Rounds:“It’s Just a Flesh Wound”

2. Patient Presentation CC: periorbital edema OU HPI • 35 yo WM with h/o HTN presents to the E.D. as a transfer from OSH with neck, facial, periorbital and airway swelling after getting in a fight with his brother. • He had a fever 102F prior to presentation, for which he had been given 1 dose IV Dexamethasone, Clindamycin and Ceftriaxone at OSH.

3. Patient Presentation (continued) HPI (continued) • At UofL, patient was intubated by anesthesia for airway at risk • He was then started on IV Vancomycin and Zosyn with abundant IV fluids for sepsis. • Ophthalmology consulted to rule out ocular compartment syndrome.

4. History (Hx) Past Ocular Hx: none Past Medical Hx: HTN Fam Hx: Non-contributory Meds: - Outpatient: none - Inpatient: Vancomycin, Zosyn Allergies: NKDA

5. History (continued) Social Hx: no EtOH, illicit drugs or smoking RoS: Unable to obtain (patient intubated)

6. Physical Exam Day #1 *Unable to obtain because patient intubated and not alert/oriented

7. Anterior Exam Day #1

8. Posterior Exam Day #1 Imaging from outside hospital prior to transfer: CT head, neck and face significant for soft tissue edema, no orbital cellulitis, no fractures.

9. Assessment 35yo WM with worsening periorbital edema OS > OD x 1 day with septic shock. No ocular compartment syndrome on exam, and no evidence of orbital cellulitis per CT scan from outside hospital.

10. Differential Diagnosis • Infectious: Preseptal Cellulitis • CT face findings • Septic on 2 pressors • Volume overload • High volume resuscitation • Traumatic swelling • Inflammatory reaction – unlikely • Vascular origin – very unlikely

11. Plan • Continue IV antibiotics (Vancomycin, Zosyn) • Call ophthalmology with questions or if patient’s mental status improves or if periorbital edema worsens

12. 11 days later… • Primary team: • “The patient’s father says he thinks the eyelids are getting more swollen. Can you come look at them?”

13. NECROTIZING FASCIITIS

18. By the time patient reached the OR: • He was in critical condition, with primary team noting that he had taken a turn for the worse systemically • He was on 3 pressors for septic shock with ischemia to distal extremities (so severe that he later required below-the-knee amputation) • He was completely non-responsive to basic commands

19. Within 24 hours of surgery: • Patient had drastically improved • He was weaned to only 1 pressor • He became responsive to basic commands

20. Post Op Day #3Q48h dressing changes erythromycin + xeroform gauze

21. Post Op Week #3

22. Post Op 6 weeks

23. Etiology • *Most common organism: Streptococcus pyogenes • *May have synergistic infection by facultative anaerobes (~35% of cases) • *Fungal etiologies such as Aspergillus and Candida species have also been reported in the periocular area • Our patient: • Wound cultures: Strep Pyogenes (GAS) & Candida

24. Epidemiology • Uncommon severe soft tissue infection, often associated with minor skin trauma (insect bite, surgery, etc.) • Periocular involvement in less than 10% of cases • More common in setting of: • *Immunocompromise • *Diabetes mellitus • *EtOH abuse

25. Clinical features • Early appearance similar to cellulitis • Rapid progression from red and tensely swollen to painful necrosis (“pain out of proportion to exam”) as the infection spreads rapidly along fascial planes • Significant leukocytosis (>30,000/mm3) • Relative sparing of the underlying muscle (periocular area is somewhat unique) • Approximately 30% mortality in all body sites. In the periocular area, mortality rate is lower (14.4%)

26. Workup • *Obtain cultures (blood and wound) • *consider CT scan of soft tissue • *consider additional labs per LRINEC Score • (“Laboratory Risk Indicator for Necrotizing Fasciitis”)

27. LRNIC Scoring https://www.mdcalc.com/lrinec-score-necrotizing-soft-tissue-infection

28. Management Algorithm https://www.aao.org/oculoplastics-center/necrotizing-fasciitis

29. Adjunctive Therapies IVIG helps prevent toxic shock syndrome from Group A Strep superantigens Improves the salvage of tissue viability Promotes granulation tissue as well as skin-graft take

30. Conclusions • Severe, rapidly progressive infection that spreads along fascial planes • High mortality if not treated quickly • This is a diagnosis that requires pattern recognition, and one that we simply cannot afford to miss! • Most common organism is strep pyogenes (Group A Strep) • Mainstay of treatment is surgical debridement with aggressive IV antibiotic regimen

31. References https://www.aao.org/oculoplastics-center/necrotizing-fasciitis https://www.mdcalc.com/lrinec-score-necrotizing-soft-tissue-infection Aakalu VK, Sajja K, Cook JL, et al. Group A streptococcal necrotizing fasciitis of the eyelids and face managed with debridement and adjunctive intravenous immunoglobulin. OphthalPlastReconstr Surg. 2009 Jul-Aug;25(4):332-44. 4. Lazzeri D, Lazzeri S, Figus M, et al. Hyperbaric oxygen therapy as further adjunctive therapy in the treatment of periorbital necrotizing fasciitis caused by group A streptococcus. OphthalPlastReconstr Surg. 2010 Nov-Dec;26(6):504-5 5. Semlacher RA, Taylor EJ, Golas L, et al. Safety of negative-pressure wound therapy over ocular structures. OphthalPlastReconstr Surg. 2012 Jul-Aug;28(4):e98-101

32. Special Thanks • Dr. Adhi • Dr. Gerber • Dr. Compton