Necrotizing fasciitis is a rare, life-threatening surgical infection in pregnancy with high rates of morbidity and mortality. A 15-year-old primigravid woman, at 28？weeks of gestation with no significant previous medical history, was admitted to our hospital complaining of severe left lower extremity pain and high fever the last 72？hours. During clinical examination, she had a swollen, erythematous and tender to palpation inflamed skin over the medial aspect of the upper thigh without any evidence of injury. Incision drainage was performed immediately and she received broad spectrum antibiotics. During initial laboratory examinations, diabetes mellitus was diagnosed. There was no clinical improvement over the following days. Magnetic resonance imaging (MRI) revealed subcutaneous tissue inflammation and edema of infected tissues confirming the disease entity. Multidisciplinary therapy with immediate aggressive surgical debridement of necrotic tissues, multiple antibiotics, and intensive care monitoring was performed successfully. The patient’s postoperative course was uncomplicated and skin defect was closed with split thickness skin grafting. Our case emphasized the potential immunosuppressive role of pregnancy state in conjunction with diabetes mellitus in the development of severe necrotizing soft tissue infections. 1. Introduction Necrotizing fasciitis (NF) is a rare life-threatening invasive soft tissue infection which is characterized by widespread necrosis of subcutaneous tissue, superficial fascia, and other adjacent tissue [1]. It is a surgical emergency with reported overall high mortality rate among patients with NF up to 76% [2]. It primarily involves the subcutaneous tissue and rapidly extends along superficial fascia planes [3]. Management of NF is based on early, aggressive surgical debridement of necrotic tissues, broad spectrum antibiotics, and intensive supportive care [3, 4]. Numerous aerobic and anaerobic pathogens are synergistically implicated in the pathogenesis of disease [1, 5]. NF occurs mainly in patients with predisposing factors such as diabetes mellitus, obesity, peripheral vascular disease, and immune system impairment or following a variety of injuries and surgical procedures which result in skin integrity interruption and rarely from hematogenous spread [2, 5]. Pregnancy is responsible for an immunosuppressive state, which may contribute to the development of severe necrotic soft tissue infections [6, 7]. Previous studies have showed that NF in pregnancy is rare and usually is characterized by acute onset and rapid
References
[1]
G. G. Kihiczak, R. A. Schwartz, and R. Kapila, “Necrotizing fasciitis: a deadly infection,” Journal of the European Academy of Dermatology and Venereology, vol. 20, no. 4, pp. 365–369, 2006.
[2]
D. G. Gallup, M. A. Freedman, R. V. Meguiar, S. N. Freedman, and T. E. Nolan, “Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency,” American Journal of Obstetrics and Gynecology, vol. 187, no. 2, pp. 305–311, 2002.
[3]
F. Catena, M. La Donna, L. Ansaloni, S. Agrusti, and M. Taffurelli, “Necrotizing fasciitis: a dramatic surgical emergency,” European Journal of Emergency Medicine, vol. 11, no. 1, pp. 44–48, 2004.
[4]
D. V. Seal, “Necrotizing fasciitis,” Current Opinion in Infectious Diseases, vol. 14, no. 2, pp. 127–132, 2001.
[5]
D. C. Elliott, J. A. Kufera, and R. A. M. Myers, “Necrotizing soft tissue infections: risk factors for mortality and strategies for management,” Annals of Surgery, vol. 224, no. 5, pp. 672–683, 1996.
[6]
P. J. Krause, C. J. Ingardia, L. T. Pontius, H. L. Malech, T. M. LoBello, and E. G. Maderazo, “Host defense during pregnancy: neutrophil chemotaxis and adherence,” American Journal of Obstetrics and Gynecology, vol. 157, no. 2, pp. 274–280, 1987.
[7]
A. Stagnaro-Green, S. H. Roman, R. H. Cobin, E. El-Harazy, S. Wallenstein, and T. F. Davies, “A prospective study of lymphocyte-initiated immunosuppression in normal pregnancy: evidence of a T-cell etiology for postpartum thyroid dysfunction,” Journal of Clinical Endocrinology and Metabolism, vol. 74, no. 3, pp. 645–653, 1992.
[8]
C. R. McHenry, T. Azar, A. J. Ramahi, and P. L. Collins, “Monomicrobial necrotizing fasciitis complicating pregnancy and puerperium,” Obstetrics and Gynecology, vol. 87, no. 5, pp. 823–826, 1996.
[9]
E. P. Dellinger, “Severe necrotizing soft-tissue infections. Multiple disease entities requiring a common approach,” Journal of the American Medical Association, vol. 246, no. 15, pp. 1717–1721, 1981.
[10]
C. R. McHenry, J. J. Piotrowski, D. Petrinic et al., “Determinants of mortality for necrotizing soft-tissue infections,” Annals of Surgery, vol. 221, no. 5, pp. 558–565, 1995.
[11]
P. Saiag, C. Le Breton, M. Pavlovic, N. Fouchard, G. Delzant, and J.-M. Bigot, “Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis,” Archives of Dermatology, vol. 130, no. 9, pp. 1150–1158, 1994.
[12]
D. B. Drake, J. A. Woods, T. J. Bill et al., “Magnetic resonance imaging in the early diagnosis of group a β streptococcal necrotizing fasciitis: a case report,” Journal of Emergency Medicine, vol. 16, no. 3, pp. 403–407, 1998.
[13]
T. E. Brothers, D. U. Tagge, J. E. Stutley, W. F. Conway, H. Del Schutte Jr., and T. K. Byrne, “Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity,” Journal of the American College of Surgeons, vol. 187, no. 4, pp. 416–421, 1998.
[14]
J. A. Majeski and J. W. Alexander, “Early diagnosis, nutritional support, and immediate exensive debridement improvesurvival in necrotizing fasciitis,” American Journal of Surgery, vol. 145, no. 6, pp. 784–787, 1983.
[15]
R. G. Ward and M. S. Walsh, “Necrotizing fasciitis: 10 years' experience in a district general hospital,” British Journal of Surgery, vol. 78, no. 4, pp. 488–489, 1991.
[16]
B. D. Bilton, G. B. Zibari, R. W. McMillan, D. F. Aultman, G. Dunn, and J. C. McDonald, “Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study,” American Surgeon, vol. 64, no. 5, pp. 397–401, 1998.
[17]
K. Korhonen, “Hyperbaric oxygen therapy in acute necrotizing infections with a special reference to the effects on tissue gas tensions,” Annales Chirurgiae et Gynaecologiae, no. 214, pp. 7–36, 2000.
[18]
R. Kaul, A. McGeer, A. Norrby-Teglund et al., “Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome—a comparative observational study,” Clinical Infectious Diseases, vol. 28, no. 4, pp. 800–807, 1999.
