Abstract
Background: Necrotizing fasciitis is a rare condition. We report a fatal case arising from an episiotomy in a previously healthy woman.
Case: A healthy 23-year-old prima gravida white female underwent vaginal delivery with repair of a proctoepisiotomy. Eighty-four hours postpartum, she developed increasing perineal swelling with severe pain. She presented on the 4th postpartum day with edema, erythema localized to the perineum, and vital signs significant only for tachycardia of 120/min. With a leukocytosis of 45,000/μl (87%) neutrophils, she was admitted to the hospital with an initial diagnosis of perineal cellulitis and empirically started on broad-spectrum intravenous antibiotic therapy. The patient's condition continued to deteriorate and she was then transferred to our facility on postpartum day 9 where a team performed two radical debridements of all necrotic tissue. Despite this and a broadened antibiotic coverage, the patient eventually experienced cardiopulmonary arrest and died on postpartum day 12.
Conclusion: Necrotizing fasciitis must be considered in the differential diagnosis of the postpartum patient presenting with severe vulvar pain and erythema. Our patient exemplifies the obscure presentation with seemingly minimal skin changes. Any delay in diagnosis and treatment, which must include expeditious aggressive surgical debridement, will likely result in severe morbidity or mortality.
Full Text
The Full Text of this article is available as a PDF (278.8 KB).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Addison W. A., Livengood C. H., 3rd, Hill G. B., Sutton G. P., Fortier K. J. Necrotizing fasciitis of vulvar origin in diabetic patients. Obstet Gynecol. 1984 Apr;63(4):473–479. [PubMed] [Google Scholar]
- Ammari N. N., Hasweh Y. G., Hassan A. A., Karyoute S. Post-partum necrotizing fasciitis. Case report. Br J Obstet Gynaecol. 1986 Jan;93(1):82–83. doi: 10.1111/j.1471-0528.1986.tb07819.x. [DOI] [PubMed] [Google Scholar]
- Hoffman M. S., Turnquist D. Necrotizing fasciitis of the vulva during chemotherapy. Obstet Gynecol. 1989 Sep;74(3 Pt 2):483–484. [PubMed] [Google Scholar]
- Nolan T. E., King L. A., Smith R. P., Gallup D. C. Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients. South Med J. 1993 Dec;86(12):1363–1367. doi: 10.1097/00007611-199312000-00008. [DOI] [PubMed] [Google Scholar]
- Piper J. M., West P. Necrotizing fasciitis following postpartum tubal ligation. A case report and review of the literature. Arch Gynecol Obstet. 1995;256(1):35–38. doi: 10.1007/BF00634347. [DOI] [PubMed] [Google Scholar]
- Salvino C., Harford F. J., Dobrin P. B. Necrotizing infections of the perineum. South Med J. 1993 Aug;86(8):908–911. doi: 10.1097/00007611-199308000-00012. [DOI] [PubMed] [Google Scholar]
- Stamenkovic I., Lew P. D. Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med. 1984 Jun 28;310(26):1689–1693. doi: 10.1056/NEJM198406283102601. [DOI] [PubMed] [Google Scholar]
- Stephenson H., Dotters D. J., Katz V., Droegemueller W. Necrotizing fasciitis of the vulva. Am J Obstet Gynecol. 1992 May;166(5):1324–1327. doi: 10.1016/0002-9378(92)91597-4. [DOI] [PubMed] [Google Scholar]
- Sutton G. P., Smirz L. R., Clark D. H., Bennett J. E. Group B streptococcal necrotizing fasciitis arising from an episiotomy. Obstet Gynecol. 1985 Nov;66(5):733–736. [PubMed] [Google Scholar]