Necrotizing Fasciitis and Cavernous Sinus Thrombosis: Nuances of a Small Furuncle

Dear Editor,

The incidence of complications in facial cellulitis is rare, especially with early medical attention, widespread and early use of antibiotics, and healthcare facilities. The complications include necrotizing fasciitis of the face, cavernous sinus thrombosis, pneumonia, and sepsis. Recently, during the COVID-19 pandemic, cutaneous mucormycosis emerged as an important and common differential for necrotizing fasciitis of the face secondary to facial cellulitis. This is the report of one such case, which has all the aforementioned complications in a person with no pre-existing immunocompromised condition.

A 42-year-old male laborer presented to the outpatient department with a history of popping a furuncle over the lower lip. Subsequently, within 5 days, he developed rapidly progressive swelling of the right side of his face and right lower lip [Figure 1a]. He also had a fever for the past 3 days. There was no history of headache, altered sensorium, or double vision. There was no prior history of hospitalization or over-the-counter drug use prior to admission. He did not suffer from COVID-19 in the past 6 months. There was no history of recurrent sinopulmonary infections. He was nondiabetic and his HIV test was negative. There was no clinical or radiological evidence of tuberculosis. No other history suggestive of underlying immunodeficiency. The patient was admitted with the provisional diagnosis of right facial cellulitis and right orbital cellulitis (Chandler grade 1), and was administered intravenous amoxicillin with clavulanic acid and metronidazole. On the second day of admission, he developed multiple pus points on the face, and an incision and drainage were performed. The next day (day 3), he had a drop in blood pressure and peripheral saturation (SpO₂). So, he was shifted to the intensive care unit, where he was diagnosed with severe interstitial pneumonia with sepsis. Blood culture revealed methicillin-sensitive Staphylococcus aureus, and pus culture from the wound showed the growth of methicillin-resistant Staphylococcus aureus. Culture-directed antibiotics were administered along with oxygen support. A Real time polymerase chain reaction test for COVID-19 was negative on nasopharyngeal and oropharyngeal swabs.

Figure 1.

Status of the patient (a) at day 4 of at admission (onset of necrotizing fasciitis) (b) after serial debridement of necrotic tissue

Despite aggressive antibiotic therapy and adequate surgical drainage, the patient developed lateral gaze restriction in the right eye on day 4, followed by facial necrotizing fasciitis [Figure 1a]. A KOH mount of necrotic crust and its fungal culture ruled out mucormycosis. The right cavernous sinus showed a filling defect on computed tomography with intravenous contrast [Figure 2a and b]. Severe interstitial pneumonia is seen in chest X-ray and high resolution computed tomography [Figure 3a and b]. Unfractionated heparin was administered regularly. We performed serial debridement [Figure 1b], eventually leading to a lower lip defect causing oral incontinence. So, Ryle’s tube feeding was initiated.

Figure 2.

Computed tomography with intravenous contrast shows (a) heterogenously enhancing soft tissue density lateral to the body of mandible on right side of face with fat stranding with an air tract (Star) (due to incision and drainage) and (b) filling defect in the right cavernous sinus (arrow)

Figure 3.

Severe interstitial pneumonia is seen in Chest X ray PA view (a) and high resolution computed tomography of chest (b) By the end of 1 month of hospital stay, the pneumonia had resolved. PA view (c)

During the 14-day intensive care unit stay, the patient required BiPAP support and was gradually weaned off oxygen and shifted to the ward on day 16. Pus from the wound persisted, which on culture showed carbapenemase-producing Klebsiella pneumoniae and extended-spectrum beta-lactamase producing Proteus mirabilis. The antibiotics were changed accordingly By the end of 1 month the pneumonia had resolved [Figure 3c]. The lower lip defect was closed by wedge resection and repair on day 28. The final defect measured 7 × 5 cm with contractures everting the lower lip, resulting from healing by secondary intention [Figure 4a].

Figure 4.

(a) preoperative condition of the wound after two and a half months, (b) skin markings for bilobed flap repair, (c) after reconstruction of wound with the flap, and (d) two months after reconstruction

The final defect was closed nearly two and a half months after the course of the illness started. We harvested a bilobed flap from neck and used it for the repair of the residual defect [Figure 4b-d]. We also kept the patient on oral warfarin therapy for the next month, with an INR in the range of two to three. The right abducens nerve palsy improved by the end of 2 months of anticoagulant therapy. A day-wise event related to the case is summarized in Figure 5.

Figure 5.

Timeline of the case starting from the appearance of the first symptom. C/S = Culture and sensitivity, ICU = Intensive care unit, MRSA = Methicillin resistant Staphylococcus aureus, ESBL = Extended spectrum beta-lactamase, pta = prior to admission, SpO₂ = peripheral saturation of oxygen

Facial cellulitis is a rapidly spreading infection of the skin and subcutaneous tissue. Causative organisms implicated commonly are beta-hemolytic Streptococcus and Staphylococcus aureus. Prevention of complications is by abstaining from manipulation of cellulitis in the dangerous area of the face. Complications of facial cellulitis are necrotizing fasciitis, toxic shock syndrome, and sepsis.

Necrotizing fasciitis is a rapidly progressing infection in fascial planes leading to necrosis of subcutaneous tissue and overlying skin. It may progress to systemic toxemia and has mortality ranging from 20% to 60%.[1] Evolution of necrotizing fasciitis from a furuncle is a rare occurrence, especially in this modern era of antibiotics. The absence of any underlying immunocompromised state further makes such cases challenging to the clinician.

Cavernous sinus thrombosis can be a complication due to the involvement of danger ous area of the face because of valveless veins connecting the facial venous system with the cavernous sinus via the ophthalmic vein, deep pterygoid plexus, and indirectly via the inferior ophthalmic vein. Cavernous sinus thrombosis was almost always fatal in the pre-antibiotic era and reduced dramatically to 20%-30% in the post-antibiotic era.[2,3] A Cochrane systematic review found two small studies with a total 79 patients with cerebral venous thrombosis comparing anticoagulant therapy with placebo. Meta-analysis of these studies showed a reduction in poor outcome rates in patients treated with unfractionated heparin or low-molecular-weight heparin.[4] But the studies included in the systematic review do not include the cases of cavernous sinus thrombosis. Retrospective reviews show a significant decrease in mortality and neurologic morbidity in cases where anticoagulants were combined with antibiotics for septic cavernous sinus thrombosis.[5] The American Heart Association (AHA)/American Stroke Association (ASA) guidelines recommend anticoagulation for 3-6 months in provoked cerebral venous thrombosis with target international normalized ratio of 2-3.[6] In patients with an infection of the head or neck, there was no significant difference in the frequency of new intracerebral hemorrhage and poor outcomes between patients who did or did not receive therapeutic doses of heparin.[7] No trials exist for the choice of anticoagulant therapy.

In conclusion, skin and soft-tissue infections should be closely monitored if found in clinical progression In absence of a known history of immunocompromised states, a detailed evaluation of adult onset immunodeficiency should be performed in case of development of cellulitis and necrotizing fasciitis, along with adequate antibiotic coverage with surgical debridement. The prognosis of cavernous sinus thrombosis can be improved by early recognition, prompt antibiotics, and anticoagulants administration.

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