Interactive Cardiovascular and Thoracic Surgery 2:358-360(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Necrotizing fasciitis of chest wall complicating empyema thoracis
M.S. Kalkat,
P.B. Rajesh* and
C. Hendrickse
Department of Thoracic Surgery, Birmingham Heartlands Hospital and Solihull NHS Trust, Bordesley Green East, Birmingham B9 5ST, UK
* Corresponding author. Tel.: +44-121-424-3561; fax: +44-121-424-3561
p_rajesh51{at}yahoo.com
Received October 12, 2002;
received in revised form December 30, 2002;
accepted February 25, 2003
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Abstract
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Necrotizing fasciitis affecting the chest wall is a rare condition and carries high mortality. It spreads rapidly, requiring early diagnosis and immediate extensive surgical debridement. The case of a 32 year old man afflicted with this uncommon condition following tube thoracostomy for empyema thoracis is described and literature reviewed.
Key Words: Necrotizing fasciitis; Empyema thoracis
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1. Introduction
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Necrotizing fasciitis may involve any part of the body and usually follows trauma or a surgical procedure. The usual polymicrobial synergistic infection results in vascular thrombosis, necrosis of subcutaneous and fascial tissue associated with systemic toxicity. However the involvement of the chest wall is relatively rare, associated with delayed diagnosis and carries a 67% mortality rate [1].
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2. Case report
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A 32 year old man was hospitalized at a peripheral hospital with right sided pleuritic chest pain, fever, cough and shortness of breath of 2 weeks duration. He had recently been drinking excessive amounts of alcohol, smoking heavily and neglecting himself following the death of his wife. Clinical and radiological examination revealed patchy consolidation in the right lower lobe with hydropneumothorax. An intercostal chest drain was inserted which drained purulent fluid. This grew staphylococcus aureus and mixed anaerobes and he was started on amoxycillin and metronidazole. After 2 weeks of conservative management his pyrexia persisted, chest auscultation revealed coarse breath sounds on right side with diminished air entry at the base. His inflammatory markers continued to rise. Chest X-ray and computed tomography (CT) scan of chest showed loculated collection with compression atelectasis of the right lower lobe. He was transferred to the thoracic surgical unit for further management. On examination apart from the above findings, he was found to have erythematous, mottled, oedamatous and tender area all over the lateral side of chest wall around the intercostal chest drain, which was draining yellowish thick purulent fluid. In view of the ongoing sepsis and poor condition of the patient it was decided to proceed with an emergency operation. Under general anaesthesia, with single lung ventilation and left lateral decubitus position, a right posterolateral thoracotomy was carried out with aim to decortication. The subcutaneous tissue and muscle were all found to be swollen and necrotic. There was thrombosis of the blood vessels with no bleeding from the tissues. After formal decortication and clearing of the pleural cavity, two intercostal drains were inserted and ribs reapproximated. Extensive debridement of the necrotic tissue was carried out exposing an area from tip of scapula, down to groin, anteriorly and posteriorly crossing midline including lumbosacral region. The latissmus dorsi, parts of serratus anterior, pectoralis major, external oblique, internal oblique and rectus sheath along with overlying subcutaneous tissue and skin were resected (Fig. 1). The resection included all visible necrotic, unhealthy tissues and was extended till bleeding tissues could be seen. The raw wound was then covered with Betadine soaked gauze dressings and patient was electively ventilated in the intensive care unit. The resected specimen grew staphylococcus aureus and mixed anaerobes. The patient was treated with ciprofloxacin and metronidazole following advice from the microbiologist and result of sensitivities of cultures. The wound was inspected daily to ensure tissue viability and it required further three to four debridements, mainly in the poster inferior area. After 1 month the wound which was healthy was covered with split skin grafts. His stay in the ITU was eventful requiring ventilation, tracheostomy and inotropic support. He made slow and steady progress and was discharged home in 5 weeks time. He continues to be followed up and is doing well (Fig. 2).
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3. Discussion
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Necrotizing fasciitis is a rare, critically serious infection of the subcutaneous tissue and fascia with relative sparing of overlying skin and underlying muscles, which can become infected secondarily. It can occur in any age group, the mean age varying from 32 to 57 years [2]. Commonly affected body sites are the lower extremeties, perineum and abdominal wall, but has rarely been reported involving the chest wall.
The predisposing factors include advanced age, infection, immunedeficiency, diabetes mellitus, steroids, chronic renal failure, alcoholism and surgical procedures on oseophagus [1], breast [3] and lungs [4] including tube thoracostomy [5]. Occasionally it may follow insect bites [2], distant infections such as paronychia [6] or may arise de novo [2]. The patient usually appears moderate to severely toxic, but early on, the patient may look deceptively well, as in the described case. The initial presentation consists of erythematous, tender, swollen area resembling cellulitis which rapidly enlarges to involve adjacent areas. As it progresses, the infection gives way to dusky or purplish skin discoloration which may become necrotic with bullae formation and eventually appears haemorrhagic and gangrenous. The presence of crepitus on examination and soft tissue air on plain X-ray is pathognomonic of necrotizing fasciitis, but is present in only 37 and 57% of the patients, respectively [7]. Subcutaneous crepitus can be overlooked as it is also a complication of tube thoracostomy. Although the cutaneous manifestations appear late, yet other signs of advanced infection are present, which include fever, tachycardia, hypotension and raised markers of inflammation. A biopsy of subcutaneous tissue and fascia for frozen section analysis may permit diagnosis in questionable cases [8]. The diagnosis is primarily a clinical one and investigations like chest X-ray, CT scan, magnetic resonance imaging are only adjuncts in the evaluation of these patients.
The common microorganisms responsible for the necrotizing fasciitis include Group A streptococci, enterococci, coagulase negative staphylococci, clostridium, Escherichia coli, enterobacter, pseudomonas, proteus and bacteroides. The infection is polymicrobial in about 70% of the cases and half of these contain mixed aerobic and anaerobic organisms. Group A streptococci has been isolated from 16 to 71% of the patients of necrotizing fasciitis [2].
The patients suspected with necrotizing fasciitis should be empirically started on broad spectrum antibiotics and guided later on by the sensitivities of the organisms identified from debrided specimens. The patient should be operated without delay and subjected to extensive debridement of the skin, subcutaneous tissue and muscle [1,2,9]. The debridement should include all the infected, dessicated tissues and extend till bleeding healthy edges are seen. It is advisable to remove more tissue than to leave any infected tissue.
Repeated visits to operation theater may be necessary. The daily dressings and inspection of the raw area is followed by covering the soft tissues with skin grafts once the infection is controlled. Postoperatively these patients require intensive care to manage the ventilation and multiorgan dysfunction that ensue. There are some reports advocating hyperbaric oxygen as an adjunct for management of these patients, but this remains controversial [7,10].
Mortality from necrotizing fasciitis of chest wall is high. Early death is usually from overwhelming sepsis and later multiorgan failure accounts for the high mortality. Delay in the diagnosis and subsequent surgical management are important predictors of mortality. An increased index of suspicion in unexplainably sick thoracic patients and aggressive surgical intervention results in favourable outcome.
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4. Conclusion
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Necrotizing fasciitis of the chest wall is a fairly uncommon condition and the diagnosis can be missed at the initial presentation being masked by the underlying pleuropulmonary infection. The diagnosis is made clinically and early surgical intervention is mandatory for these patients.
doi:10.1016/S1569-9293(03)00050-1
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References
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- Losanoff JE, Jones JW, Richman BW. Necrotising soft tissue infection of the chest wall. Ann Thorac Surg. 2002;73:304–306[Abstract/Free Full Text]
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- Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC. Improved results from a standardized approach in treating patients with necrotizing fascicitis. Ann Surg. 1987;206:661–665[Medline]
- Riseman JF, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery. 1990;108:847–850[Medline]
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Abstract
1. Introduction
