INTRODUCTION Necrotizing fasciitis is an uncommon and severe invasive soft tissue infection characterized by cutaneous gangrene, suppurative fasciitis, and vascular thrombosis. The disease is usually preceded by penetrating trauma in patients that have systemic problems, most commonly diabetes, alcoholism, and immunosupression, but may occur after blepharoplasty or other eyelid surgery. Necrotizing fasciitis represents a synergistic polymicrobial soft tissue infection with the release of endogenous cytokines and bacterial toxins. The disease is most frequently attributed to group A Streptococcus and Staphylococcus aureus. The mortality rate overall is 34%, and for those cases with periorbital involvement it is 12.5%. Death usually results from a fulminant course that may lead to septic shock, respiratory distress syndrome, and renal failure. The average age at time of infection is 57 years, but it may be seen in all age groups.
CLINICAL PRESENTATION Clinical features include presence of cellulitis with dusky, violaceous discoloration of the eyelid skin, often with bullae formation. Infection of the superficial and deep tissue results in thrombosis of subcutaneous vessels and subsequent necrosis of the overlying skin. Gas crepitation with copious foul-smelling drainage may be present. The patient is febrile and may appear septic. Hypotension, hypercalcemia, and disorientation may also be seen. Complications include
cicatricial ectropion and subsequent corneal ulceration, and visual loss from orbital invasion and ophthalmic artery occlusions.
HISTOPATHOLOGY Necrotizing fasciitis is manifest histologically by edema, severe necrosis, and mixed acute and chronic inflammation involving the skin and subcutaneous tissue, including fascial planes. Vasculitis and vascular thrombosis are common, as are skeletal muscle necrosis and colonies of bacteria (illustrated below). Necrotizing cellulitis differs from necrotizing fasciitis by lack of extension of the inflammation and necrosis into the subcutaneous tissue planes.
DIFFERENTIAL DIAGNOSIS The differential diagnosis includes preseptal cellulitis, erysipelas, thermal injury, frostbite, electrical burn, trauma, venom reaction, mucormycosis, anthrax infection, embolic event, or pressure necrosis.
TREATMENT Treatment necessitates prompt wide surgical debridement of all necrotic fascia, subcutaneous tissue, and muscle. Multiple debridements may be necessary in up to 30% of cases. Broad spectrum parenteral antimicrobial therapy, including penicillin and clindamycin, has been shown to produce higher survival rates. In some cases with only eyelid involvement a more conservative nondestructive debridement and antimicrobial therapy may give good results. Ancillary treatment includes hyperbaric oxygen therapy and intravenous immunoglobulin therapy which can reduce wound morbidity and the overall mortality. Reconstruction usually requires skin grafts to repair the cutaneous defects and resulting cicatricial ectropion.
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