Enabling the diagnosis of necrotising fasciitis without associated skin changes in a paediatric patient with acute lymphoblastic leukaemia: The LRINEC score

Hamilton, R.J.; Song, Colin; Kong, Tze; Lo, Steven

doi:10.1016/j.bjps.2014.08.044

Cited by 5 publications

(2 citation statements)

References 4 publications

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“…15 However, this score has not been validated for paediatric patients 7 and only one report describes its successful use in a paediatric patient. 16 Hence, the LRINEC in a paediatric case-control study of 20 cases of necrotising fasciitis and 20 controls diagnosed with non-necrotising soft tissue infections was found to be inferior to a modification that takes only sodium <135 mmol/L and CRP>20 mg/L into account. 17 In our case, we conducted the first blood analysis after the second surgery on admission to the paediatric intensive care unit, which was after the initially missed diagnosis of necrotising fasciitis had already been established intra-operatively.…”

Section: Discussionmentioning

confidence: 97%

Necrotising fasciitis following a supracondylar fracture and an open radius fracture in a child

et al. 2018

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Background: Necrotising fasciitis is a rare, rapidly progressing soft-tissue infection with a high mortality rate. Historically, necrotising fasciitis has been associated with penetrating injuries, and more recently with immunocompromise and severe comorbidities. This case report highlights the association of necrotising fasciitis in a child with an open distal radius fracture and a supracondylar fracture. Method and results (case report): A 10-year-old boy was admitted 24 hours after falling from a tree with a Gustilo and Anderson grade II distal radius fracture and a Gartland grade III supracondylar humerus fracture. The wound was debrided and the fractures reduced and stabilised with Kirschner wires. Within 48 hours of admission he developed a necrotising fasciitis that extended onto the chest and eventually resulted in a shoulder disarticulation. The tissue defects were covered with flaps and skin grafts and the patient was discharged home. Conclusions: This case highlights the importance of having an early and high index of suspicion for necrotising fasciitis in a child with an open contaminated fracture and delay to both antibacterial chemotherapy and surgical debridement. Tissue trauma due to open fractures may obscure the early skin signs of necrotising fasciitis as well as laboratory risk factors. In the South African context, urgent administration of cephazolin and surgical exploration must be done to prevent the devastating complication of necrotising fasciitis.

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Section: Discussionmentioning

confidence: 97%

Necrotising fasciitis following a supracondylar fracture and an open radius fracture in a child

et al. 2018

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“…4 One case report in a patient with leukaemia suggested that the LRI-NEC score may be helpful in an equivocal case of necrotising fasciitis. 5 However, there have been no prospective trials validating this score. In our patient, although this score was 12, which is high, it may be biased because of pathological findings related to the underlying malignant disease.…”

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An atypical presentation of necrotising fasciitis

Kunz

Seidel

Weidhase

et al. 2017

annals

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Necrotising fasciitis is a rare infection with a high mortality rate. Clinical manifestation may be influenced by an underlying disease state. We report a case of a 70-year-old man with an anaplastic large-cell lymphoma who presented with inconclusive signs of necrotising fasciitis following a neutropenic phase after chemotherapy. Surgical exploration did not reveal the typical macroscopic features of necrotising fasciitis. Microbiological investigations revealed Escherichia coli. The lack of massive tissue inflammation, probably due to the neutropenia in our patient, has not been described by other authors. Diagnostic uncertainties owing to masked or uncharacteristic signs in immune compromised patients may lead to a delayed surgical debridement, of which clinicians should be aware. KEYWORDS Necrotising Fasciitis Case reportA 70-year-old man was admitted to our hospital with impaired vision and a downbeat nystagmus. He had a history of anaplastic large-cell lymphoma that was in remission following chemotherapy. However, magnetic resonance imaging (MRI) and a spinal tap on admission confirmed the clinical suspicion of a lymphomatous meningitis. Intrathecal followed by systemic high-dose methotrexate (6640 mg) was administered on day 16 after admission. The patient developed neutropenia on day 20. A mild swelling of the left thigh, with marked pain, fever, tachycardia and tachypnoea were observed on day 23, and the patient was transferred to the intensive care unit (ICU). Laboratory workup revealed a serum C-reactive protein of 438 mg/l and procalcitonin of 33.7 ng/ml. Maximum blood lactate in the first 24 hours after ICU admission was 2.9 mmol/l.An MRI of the left leg showed a slight oedema of the gastrocnemius muscle with no pathological enhancement of the fascia (Fig 1). Antibiotic therapy with imipenem/cilastatine was started and a senior surgeon was immediately consulted, because of the high suspicion of necrotising fasciitis. Surgical exploration of the left leg revealed no typical macroscopic signs of necrotising fasciitis. Only slight bleeding in the soleus and flexor hallucis longus muscles was observed. Tissue biopsy and smears were sent for diagnostic workup and a primary wound closure was performed as the macroscopic features made necrotising fasciitis seem unlikely. Histology showed inflammation and necrosis of the superficial fascia with polymorphonuclear cell infiltration highly suspicious of necrotising fasciitis (Fig 2). Fibrinoid thrombi and necrosis of vessel walls were not observed.The microbiological workup revealed growth of Escherichia coli in the biopsy specimens and the blood cultures. These findings, together with the continuing systemic inflammation, warranted a surgical second look, which was carried out on day 25. Once again, no suspicious signs of necrotising fasciitis were found. Nevertheless, the medial parts of the fascia were excised and the surgical wound was closed. A radical removal of the infected tissue was not certain because of the missing tissue boundaries betwee...

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Re: ‘Enabling the diagnosis of necrotising fasciitis without associated skin changes in a paediatric patient with acute lymphoblastic leukaemia: The LRINEC score’

Cahill

2015

Journal of Plastic, Reconstructive & Aesthetic Surgery

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Enabling the diagnosis of necrotising fasciitis without associated skin changes in a paediatric patient with acute lymphoblastic leukaemia: The LRINEC score

Cited by 5 publications

References 4 publications

Necrotising fasciitis following a supracondylar fracture and an open radius fracture in a child

Necrotising fasciitis following a supracondylar fracture and an open radius fracture in a child

An atypical presentation of necrotising fasciitis

Re: ‘Enabling the diagnosis of necrotising fasciitis without associated skin changes in a paediatric patient with acute lymphoblastic leukaemia: The LRINEC score’

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