Necrotizing fasciitis with toxic shock syndrome in a child: a case report and review of literature

INTRODUCTION: Necrotizing fasciitis was described as early as the fifth century BC. It showed an increased incidence worldwide in the past several years. CASE PRESENTATION: An 8-year-old Arabian boy was referred for admission as a case of cellulitis of the left thigh. Ten days prior to admission he had a cat scratch to his left thigh and the parents did not seek medical advice at that time. The child was again examined by orthopedic surgeon and a diagnosis of cellulites was made at that time. Physical examination on admission revealed a very toxic appearing weak child with cold extremities and poor peripheral perfusion. Examination of the left thigh revealed extensive swelling, induration and edema with dusky skin, blistering and bleb formation, in addition to an area of gangrenous skin. Laboratory investigation revealed white blood cell count of 22,400 × 10(9 )with toxic granulation on peripheral blood smear. The child was admitted to the pediatric intensive care unit and dopamine and dobutamine infusions were started after volume expansion. Penicillin and clindamycin also were started in addition to multiple transfusions of fresh frozen plasma. Surgical debridement of all necrotic tissues and drainage of involved fascia planes via extensive fasciotomy were done for our patient after stabilization of his vital signs and improvement of his general condition. Blood cultures grew group A streptococcus, as did wound swab culture. The child showed great improvements in his clinical condition after the 3(rd )day of antibiotics and supportive treatment and the wound healed normally and antibiotics were administered for 21 days. CONCLUSION: Necrotizing fasciitis in children is a frequently misdiagnosed condition; early identification of the necrotizing process can improve the outcome of this life-threatening disease. Surgical debridement and antibiotics were the most important therapeutic measures.