1. UNUSUAL PRESENTATION OF
BILATERAL NECROTIZING FASCIITIS IN THREE CHILDREN
IN BRUSSELS
KARASTATHI C. (1), BULCKAERT D. (2), DE MEY I. (3), CIFCI L.(3), BAYET B. (1), LAFOSSE A. (1), HUBLOUE I. (2), VANCLAIRE J. (3), VAN DER LINDEN D. (1)
(1)Paediatric infectious diseases, General Paediatrics, Cliniques universitaires St Luc,UCL, Brussels, (2)Paediatric Emergency Department and Intensive Care Unit of Universitair Ziekenhuis Brussels, VUB (3)General Paediatric Department of Saint Jean Clinic, Brussels, Belgium
Background:
Necrotizing Fasciitis (NF) is a rare, rapidly progressive and life-threatening bacterial infection of the fascia and subcutaneous
cellular tissue. Although the first report dates from the fifth century by Hippocrates, the variable aspects of the skin presentation
and non specific laboratory findings make the prompt diagnosis very difficult. We report 3 cases of group A Streptococcus (GAS)
-related NF in immunocompetent children with bilateral expression within a period of 3 months in Brussels which is exceptional
since epidemiological studies show an annual incidence of 0,13-0,21 per 100,000 children.
Case 2:
A 4-month-old boy with history of anal surgery presented with a
streptococcal toxic shock syndrome (STSS) associated with
meningitis and otitis media. An explorative laparoscopy performed
for an important abdominal distention was non-contributive. His
clinical progress was complicated with NF of both flanks (Fig 3),
confirmed by ultrasound (Fig 4) and requiring two large consecutive
debridements (Fig 5).
Case 3:
A 1.5-year-old girl presented
with a STSS,
extreme pain and edema of
both hands and refusal to
walk. A few days before,she
was diagnosed with a
pharyngitis and bilateral otitis
media. Antibiotics were not
administrated. 24h after
admission progressive
anesthesia of the right thumb
was noted requiring urgent
surgical exploration.
Case 1:
A 3-year-old girl admitted for fever
and severe pain of both legs in a
context of a streptococcal tonsillitis
and otitis media. The diagnosis of
NF was confirmed 18h after her
admission by ultrasound and an
emergent drainage of the suspected
areas was performed.Due to
development of necrotic
hemorrhagic lesions(Fig1),a large
debridement was done the
following day.(Fig2)
Fig 3
Fig 4
OUR PATIENTS:
Case 1
Case 2
Case 3
LRINEC score 9 8 6
Finger Test
Frozen Biopsy No
Throat swab
Blood Culture
CSF
Tissue Bacteriology
GABHS (+)
Negative
Not done
Analyses of GABHS
SpeA,B,F-
emm1
SpeA,B,F–
Spe A,B,F-
emm3
Clinical outcome
Survival
Death
Fig 2
Fig 1
Fig 5
Suspicion of NF: Proposed Algorithm
LRINEC SCORE
(Wong, Crit Care Med, 2004)
CRP (mg/l)
<150
>150 4
WBC(/mm³)
<15
15-25
>25 1 2
Hb(g/dl):
>13,5
11-13,5
<11
Sodium(mmol/l) :
>135
<135
Creatinine(µmol/l)
<141
>141
Glucose (mmol/l)
<10
>10
Look for Risk Factors:
Varicella, Trauma, Chronic illness, Intravenous drug abuse, Surgery, Immunodeficiency
Diagnostic Tools for
Necrotiozing Fasciitis:
LRINEC Score:
The Laboratory Risk Indicator for
Necrotizing Fasciitis has not been
studied in children. Scores greater than
6 have a positive predictive value of 92%
for NF and a negative predictive value
of 96%
FINGER TEST:
After local anesthesia, a 2cm incision is
made down to deep fascia. Lack of
bleeding is a sign of NF. Sometimes,
¨dishwasher¨ colored fluid is seeping
from the wound. A gentle maneuver with
The index finger is performed.If the
tissues dissect with minimal resistance,
the ¨finger¨test is positive.
FROZEN BIOPSY
IMAGING:
Ultrasound by a specialist. MRI more
accurate but not available immediately
Necrotic signs
+SHOCK
+/- SEPSIS, SEVERE PAIN
+/- SKIN CHANGES
Skin lesions,
No pain
High Probability of NF
Low Probability of NF
Bacteriological Samples
Blood analysis  Calculate LRINEC Score
LRINEC>6:
FINGER TEST
FROZEN BIOPSY
CULTURES OF TISSUE
LRINEC<6:
Ultrasound of
suspected area
FINDINGS OF NF
Large Debridement
Reevaluation/24h
No findings of NF
No suspicion of NF
Signs of NF :
Act like LRINEC>6
Repeat LRINEC/6h
Discuss MRI