|Year : 2013 | Volume
| Issue : 1 | Page : 55-57
Necrotizing fasciitis in an infant secondary to varicella zoster infection
Nirmala Cherukuri, K Madhusudan, J Venkateswara Rao, K Satish
Department of Pediatrics, Gandhi Medical College, Secunderabad, India
|Date of Web Publication||13-Mar-2013|
Flat No. 3, Esteem Villa, Behind Bhavans School, Vivekanadapuram North, Sainikpuri, Secunderabad - 500 094, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Necrotizing fasciitis is a potentially fatal, progressive soft tissue infection that typically occurs in adults, but rare in infants and young children. It's an uncommon but serious complication of varicella infection in children. We hereby report a case of 10 month-old-female infant who presented with necrotizing fasciitis following varicella.
Keywords: Infant, necrotizing fasciitis, varicella zoster
|How to cite this article:|
Cherukuri N, Madhusudan K, Rao J V, Satish K. Necrotizing fasciitis in an infant secondary to varicella zoster infection. J NTR Univ Health Sci 2013;2:55-7
|How to cite this URL:|
Cherukuri N, Madhusudan K, Rao J V, Satish K. Necrotizing fasciitis in an infant secondary to varicella zoster infection. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Apr 7];2:55-7. Available from: http://www.jdrntruhs.org/text.asp?2013/2/1/55/108516
| Introduction|| |
Varicella zoster Virus (VZV) is the etiological agent of varicella (primary infection) and herpes zoster (reactivation of latent infection). Although varicella is most often a relatively benign and self-limited childhood illness, the disease can be associated with a variety of serious and potentially lethal complications in both immunocompromized and immunocompetent persons. Though necrotizing fasciitis following chicken pox has been reported, literature search has revealed that it has not been reported in infants in India so far. Five cases of necrotizing fasciitis as a complication of varicella have been reported in India, but all of them are above one year, hence this case is being reported.
| Case Report|| |
A 10 month-old-female infant presented with complaints of fever and rash since one week and swelling and redness over the neck since 3 days. There was a history of papulo-vesicular rash in the elder sibling 3 weeks back, which was diagnosed as varicella. The patient's past history was of no significance and there was no history of repeated chest infections. She was immunized as per age, according to national immunization programme. Upon admission the child was accepting feeds and there was no disturbance in sleep. The physical examination revealed that the child was febrile with healed scabs over the extremities [Figure 1]. The rash was centripetal in distribution. There was puffiness around eyes with swelling and induration over the nape of the neck extending from sub-occipital region to the nape of the neck [Figure 2]. The local examination revealed indurated lesions with discoloration suggestive of necrotizing fasciitis. There was severe localized pain with a local rise of temperature.
|Figure 2: Necrotizing fasciitis lesions over the scalp and nape of the neck|
Click here to view
Her investigations revealed a leukocytosis of 13,000/cumm with neutrophil predominance and her C-reactive protein (CRP) was positive. The child was treated with intravenous ceftriaxone, metronidazole, and surgical debridement was undertaken [Figure 3]. The child responded to treatment by clinical improvement and reduction of the induration with localization of the lesion. The wound culture revealed no growth and the lesions over the scalp healed well with daily dressings but the one at the nape of the neck required a plastic surgery intervention after debridement.
|Figure 3: Necrotizing fasciitis Lesions over the nape of the neck after debridement|
Click here to view
| Discussion|| |
Necrotizing fasciitis is a rapidly progressive and often fatal infection of the soft-tissue fascia deep to skin but superficial to muscles. In general, it is classified into two types. Type I Necrotizing fasciitis refers to mixed infections involving anaerobes and one or more facultative anaerobes, such as streptococci and members of the Enterobacteriaceae family.  Type II Necrotizing fasciitis refers to infections that are caused by invasive group A beta-hemolytic streptococcus (GABHS). The most common type of Necrotizing fasciitis is type II.
Necrotizing fasciitis as a complication of varicella zoster infection is rare, but it is a serious condition with potential devastating sequelae and requires prompt diagnosis and surgical management. The condition is difficult to recognize in early phase, when it is often confused with cellulitis, but symptoms like rapid progression, poor therapeutic response, blistering necrosis, cyanosis, extreme local tenderness, high temperature, tachycardia, hypotension, and altered level of consciousness may suggest necrotizing fasciitis.  It is difficult to diagnose in children because unlike adult cases, necrotizing fasciitis in children often appears in other-wise healthy individuals who have no chronic disease or predisposition to infection. 
Complications secondary to chicken pox infection have been reported to occur in younger children. Serious complications such as necrotising fasciitis constitute <1% of the cases.  Stokes first documented soft tissue complications of varicella in 1807 and Hutchinson reported additional cases in 1882.  The average age at the time of presentation was 3.1 years as reported by Peterson et al.,  4 years by Brogan et al.,  4.6 years by Zerr et al..  Vugia et al.  reported a series of 24 children with chicken pox who suffered invasive infections; of these only a 6-month-old boy had necrotizing fasciitis. To the best of our knowledge this case appears to be the first case-report of necrotizing fasciitis following varicella in an infant (10 months old) in India as per the literary research.
In the Clark et al study,  the complications developed at an average of 5.2 days after the appearance of the vesicles compared with 3 days in the study of Brogan et al., and 4 days in the study of Waldhausen and colleagues. In our case the complication developed on the fifth day of the rash.
Given the rapid progression of infection, patients suspected of having necrotizing fasciitis must be admitted to hospital and monitored very closely. Although imaging with ultrasound, computed tomography (CT) scan and magnetic resonance imaging (MRI) have been noted to be of value in diagnosing Necrotizing fasciitis, surgical management should not be delayed in favor of these assessments. Initially the patient should be started on a combination of clindamycin and a third-generation cephalosporin that covers Pseudomonas aeruginosa. Once culture findings and bacterial sensitivity are obtained, antibiotics are administered accordingly. Antibiotics alone, because of their inability to reach the poorly vascularized and necrotic fascia, have little effect if surgery is not performed. 
In our case the swab sent for culture sensitivity was sterile and the infant had responded clinically to the third generation cephalosporins and metronidazole. Pus for culture sensitivity is positive in only 50% of cases. 
The complications of chickenpox can be prevented with vaccination for chickenpox, which has been proved effective in preventing and decreasing the severity of infection. Varicella vaccine is recommended for routine administration as a two dose regimen to healthy children at ages 12-15 months and 4-6 years. Vaccination with two doses is recommended for all persons without evidence of immunity.  The vaccine has also been found to be effective in unvaccinated children if it is given within 36 hours of exposure to chickenpox. 
The actual population based rates of this presentation in India and their outcomes is an area in need of research.
| References|| |
|1.||Giuliano A, Lewis F Jr, Hadley K, Blaisdell FW. Bacteriology of necrotizing fasciitis. Am J Surg 1977;134:52-7. |
|2.||Shirley R, Mackey S, Meagher P. Necrotizing fasciitis a sequelae of varicella zoster infection. J Plast Reconstr Aesthet Surg 2011;64:123-7. |
|3.||Nathan S, Pang AS, Singh Sidhu DS, Lam KS, Low JM. Necrotising soft tissue infections as a complication of chicken pox. Singapore Med J 1995;36:656-60. |
|4.||Clark P, Davidson D, Letts M, Lawton L, Jawadi A. Necrotizing fasciitis secondary to chickenpox infection in children. Can J Surg 2003;46:9-14. |
|5.||Hutchinson J. On gangrenous eruptions in connection with vaccination and chickenpox. Med Chir Trans 1882;65:1-12. |
|6.||Peterson CL, Mascola L, Chao SM, Lieberman JM, Arcinue EL, Blumberg DA, et al. Children hospitalized for varicella: A pre-vaccine review. J Pediatr 1996;129:529-36. |
|7.||Brogan TV, Nizet V, Waldhausen JH, Rubens CE, Clarke WR. Group A streptococcal necrotizing fasciitis complicating primary varicella: A series of fourteen patients. Pediatr Infect Dis J 1995;14:588-94. |
|8.||Zerr DM, Alexander ER, Duchin JS, Koutsky LA, Rubens CE. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics 1999;103:783-90. |
|9.||Vugia DJ, Peterson CL, Meyers HB, Kim KS, Arrieta A, Schlievert PM, et al. Invasive group A streptococcal infections in children with varicella in Southern California. Pediatr Infect Dis J 1996;15:146-50. |
|10.||Wilson HD, Haltalin KC. Acute necrotizing fasciitis in childhood. Report of 11 cases. Am J Dis Child 1973;125:591-5. |
|11.||Kaul R, McGeer A, Low DE, Green K, Schwartz B. Population-based surveillance for group A streptococcal necrotizing fasciitis: Clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study. Am J Med 1997;103:18-24. |
|12.||Indian Academy of Pediatrics Committee on Immunization (IAPCOI). Consensus recommendations on immunization and IAP immunization timetable 2012. Indian Pediatr 2012;49:549-64. |
|13.||Watson B, Seward J, Yang A, Witte P, Lutz J, Chan C, et al. Postexposure effectiveness of varicella vaccine. Pediatrics 2000;105:84-8. |
[Figure 1], [Figure 2], [Figure 3]