Necrotizing fasciitis of the chest wall is a rare disease that usually takes place as a complication of surgical procedures in the cervical region, spreading downward to the anterior chest wall, pericardium, and even the deep mediastinal structures 1 . Reports in the medical literature are very plentiful regarding necrotizing fasciitis occurring in other topographic body areas but otherwise scarce when focusing primarily on the thoracic incidence and management. Although the general therapeutic strategies used in necrotizing fasciitis are also applied to thoracic fasciitis, some special features exist that should be emphasized when dealing with thoracic necrotizing infections, beyond the unique postoperative issues involving either an intra-or extra-cardiac implanted prosthesis. The differential diagnosis between necrotizing fasciitis and non-necrotizing soft tissue infections should be a priority, as they present different prognostic and therapeutic implications 2 . In this brief communication, we focus on a literature review regarding concepts, pathophysiology, and treatment of necrotizing fasciitis and report and discuss a rare case of anterior chest wall necrotizing fasciitis as a complication of cardiac surgery. To our knowledge, no such cases have been reported in the medical literature.
Case ReportThe patient is a 38-year-old male with Marfan's Syndrome, who presented with a huge aneurysm of the ascending aorta (8 cm in diameter), severe aortic valve regurgitation, and severe left ventricular dysfunction. His previous medical history included septic shock as a complication in the postoperative period of an orthopedic procedure to the left ankle due to a traumatic fracture. At present, the surgical procedure was an aortoplasty with a composite Dacron and bovine pericardium graft (Labcor Laboratórios Belo Horizonte -Brazil), in which a double leaflet mechanical aortic prosthesis was attached Carbomedics Inc., USA, and coronary ostia reimplantation was performed. The immediate evolution included persistent fever and inflammatory signs at the upper and lower incision limits, with a yellowish discharge. Computerized tomography of the thorax and mediastinum showed a viscid pus-like collection around the aortic graft suggestive of mediastinitis. The sternum was stable. Incision and drainage of 2 incisional abscesses were performed. The infectious process spread through the neighboring tissues with formation of small abscesses, frankly purulent discharge, cellulites, and skin necrosis (Fig. 1). The first wide debridement, with resection of all apparently necrotic tissues, was performed, but soon we realized that it was ineffective (Fig. 2). Septic shock and local crepitus were established, and the diagnosis of necrotizing fasciitis of
