NECROTIZING FASCIITIS

Dear Editor,

A 47-year-old ex-serviceman presented with a large infected perianal wound as a result of drainage of perirectal abscess at a peripheral civil hospital. At admission the perianorectal wound was unhealthy and coated with greyish slough. Thorough debridement of the wound was done and supportive measures were started. There were no signs of toxaemia. Patient was not diabetic. The repeated debridement was carried out at intervals of every 2 to 3 days, but wound became unhealthy with greyish-blackish discoloration. A record number of 11 times wound debridement was carried out and 14 units of blood were transfused. Despite aggressive repeated debridement, broad-spectrum antibiotics, blood transfusions, loop sigmoidostomy and other supportive measures, patient died of fulminant sepsis. The histopathological examination of the excised tissue revealed non-specific vasculitis.

In reference to this case, I want to highlight some of the features of this dreaded disease. The synergistic necrotizing fascitis described by Fournier, is a highly lethal and rapidly progressive necrotizing infection of the perineal and genital fascia, with gangrene of the overlying skin. It is a rare disease but a life-threatening condition. Inspite of newer diagnostic techniques, the etiology remains unclear in one-fourth of cases [1]. Anorectal, genitourinary traumatic infections are the most common causes of Fournier's gangrene. The infecting organisms comprise both aerobic and anaerobic organisms such as Escherichia coli, Streptococcus pyogenes, Pseudomonas aeruginosa, Klebsiella pneumonia, Proteus mirabilis, Enterococci, Bacteroides fragilis and anaerobic Streptococcus. The early detection, extensive surgical debridement, parenteral broad-spectrum antibiotics, intravenous metronidazole, haemodynamic resuscitation and nutritional support are crucial to survival in this potentially lethal disease. Sometimes multiple surgical procedures may be necessary to bring the infection under control. In a report from literature, the surgical resection and antibiotic treatment failed to halt progression of the disease in one case but complete remission in the disease was achieved by high dose corticosteroid therapy [2]. The response to steroids suggests that Fournier's gangrene represents a local schwartzman phenomenon. Diversion of faecal and urinary streams may not always be necessary but should be considered on a case by case basis. In the present case a diverting colostomy was performed to avoid contamination of the perineal wound. The Fournier's gangrene has also been found as the presenting sign in an undiagnosed human immunodeficiency virus infection [3]. The value of hyperbaric oxygenation in Fournier's gangrene remains unproven [4]. The reported mortality rates in different series range between 22 and 60% [5]. To summarize, it is a polymicrobial synergistic infection and the aggressive surgical debridement, broad spectrum antibiotics and plastic reconstructive techniques have all contributed to a better survival of these patients in the recent years.