NECROTIZING FASCIITIS AFTER LIPOSUCTION

INTRODUCTION

Necrotizing fasciitis is a progressive soft tissue infection which causes extensive necrosis of the skin, frequently associated with septic shock (10). In two thirds of cases it involves entry into the organism of a large variety of microbes (defined as type I) (1, 6, 10), or one single isolated microbe, Streptococcus pyogenes (necrotizing fasciitis type II), mainly through surgical wounds, minor trauma, trivial wounds, ulcers and even intact skin, especially in the lower limbs (5), but it can also present in healthy patients (3, 7).

The signs and symptoms are insidious, virtually unnoticeable or non-specific in the first 48 hours. Next, rapidly spreading necrosis of the skin develops, added to intense pain (5, 6) and toxic syndrome.

Treatment is a combined antibiotic therapy, complete debridement of the necrotic tissue and maintaining of haemodynamic status (3, 6, 10, 11).

Nevertheless, despite the intensive treatment and aggressive surgery, mortality rates are high (between 20% and 70%, depending on the series consulted) (5, 10).

Various reports have been found in the literature of cases of necrotizing fasciitis following cosmetic surgery interventions, with liposuction standing out among them (2, 4, 5, 10). Healthcare professionals must familiarise themselves with the clinical signs and symptoms (7), since only early diagnosis and aggressive treatment reduce the high mortality rates (5, 9).

CASE REPORT

We report of a 29-year-old female patient, with no known drug allergies or relevant medical history, undergoing cosmetic liposuction of the torso and lower limbs at a Centre for Cosmetic Surgery.

Forty-eight hours later, during changing of dressings, she developed hypotension, oliguria and tachypnoea, which led to transfer to the Accident and Emergency Department of the nearest hospital. Analysis on admission showed: creatinine 2.4 mg/dl; leukocytes 1800.10³/l; haemoglobin 6.7 g/dl; and Quick 60%. Haematoma of abdominal wall with multiple bleeding liposuction cannula orifices presented. CT scan revealed signs of abdominal cellulitis.

The patient was admitted to Intensive Care Unit due to multiple organ failure, requiring multiple blood transfusions, vasoactive drugs, orotracheal intubation and mechanical ventilation. The liposuction cannula orifices began to suppurate and Streptococcus pyogenes was cultured, sensitive to Penicillin, only three days after the liposuction. The patient was referred to Dermatology, where skin lesions as purpura fulminans with widespread skin necrosis (25% of total body surface) were diagnosed, affecting anterior and posterior torso, thighs and left arm. Due to the progression of the sepsis and the skin necrosis, extensive debridement was carried out by General Surgery. Thirteen days after the liposuction, Pseudomonas aeruginosa and E. coli were isolated in the exudate from the wounds, and Candida albicans and Candida glabrata in the urine culture and tracheal aspirate. Treatment was then started with Piperacilin-tazobactam and caspofungin and local treatment with normal saline and chlorhexidine.

After consulting the Intensive Care Unit and Department of Plastic, Reconstructive and Cosmetic Surgery at the Hospital Universitario Vall d’Hebron, it was decided to transfer the patient there due to the progression of the sepsis and the extension of the lesions. Diagnosis included septic shock, secondary to soft tissue sepsis due to Streptococcus pyogenes, haemodynamic, renal and respiratory failure, disseminated intravascular coagulation, pancytopenia and purpura fulminans with extensive skin necrosis. On admission to the ICU in our Centre, 29 days after the liposuction and 27 days after initial admission to hospital, the wound care was changed to acetic acid every six hours and later, silver sulphadiazine twelve-hourly, while cultures were sent which grew Acinetobacter baumannii in wound exudates and tracheal aspirate.

After ten days in the ICU and given the good progress in her general condition, the patient was moved to the Burns Unit due to the extension of body surface exposed. Patient was then taken to surgery on three occasions, the first two for debridement of the granulation tissue and coverage with 1:3 skin grafts taken from the patient’s lower limbs. At the third intervention, excision of the dermo-epidermal separation in the dorsal area was performed with grafting of the bloody area. The only complications presented by the patient during her stay in the Burns Unit were a urinary infection and phlebitis, which responded to antibiotics.

Due to making good progress, patient was discharged 84 days after the liposuction and after spending 82 days in hospital. She is currently being followed up in our Centre’s Plastic Surgery Outpatient Department. (Fig. 1–6.)

DISCUSSION

Necrotizing fasciitis is a progressive soft tissue infection which causes extensive necrosis of the skin, frequently associated with septic shock (10). In two thirds of cases it involves entry into the organism of a large variety of microbes (defined as type I (1, 6, 10), or one single isolated microbe, Streptococcus pyogenes (necrotizing fasciitis type II), mainly through surgical wounds, minor trauma, trivial wounds, ulcers and even intact skin, especially in the lower limbs (5).

Streptococcus pyogenes, a catalase-negative, gram positive coccus which occurs in chains, is a betahaemolytic-type facultative anaerobe of group A, the pathogen group for humans (3). There are two serotypes, oropharyngeal and cutaneous, and the sites do not interchange (3).    10% of the healthy population are oropharyngeal carriers and 0.5–1% skin carriers, eradication not being indicated in the absence of symptoms (3). Streptococcus pyogenes causes secondary infections in humans (eczema, infestations, ulcers), vascular lesions caused by circulating erythrotoxin (scarlatina), skin lesions attributed to allergic hypersensitivity to the streptococcal antigens (erythema nodosum and vasculitis), skin lesions apparently caused or influenced by streptococcal infections (psoriasis, especially guttate forms) and direct infections of the skin and subcutaneous tissue (impetigo, ecthyma, erysipelas, cellulitis or necrotizing fasciitis) (3).

So, type II necrotizing fasciitis is an infection of the skin, subcutaneous tissue and fascia, frequently associated with septic shock and multiple organ failure and caused by Streptococcus pyogenes, the incidence of which has increased since the 1990s (10). If it affects the underlying muscle, it is called synergistic necrotizing cellulitis. Predisposing factors are thought to be immunodeficiency (the very old and the very young, alcoholism, severe chronic illness and carcinoma), peripheral vascular disease and lymphoedema, but it can also present in healthy patients (3, 7).

The pathogenic mechanisms behind this disease are pressure on the tissues, vascular thrombosis and bacterial toxins, which lead to necrosis of the skin and multiple organ failure (3).

The signs and symptoms are insidious, virtually unnoticeable or non-specific in the first 48 hours: fever, myalgia, nausea, diarrhoea, erythema (a reddish colouring of the skin with no clear margin, hot and painful when pressed); however intolerable pain may be the only symptom during the initial hours (6). Generally by days 3 and 4 an extensive area of induration will appear, blisters and, at times, dark colouring in the centre, which is a sign of poor prognosis (10). Next, rapidly spreading necrosis of the skin develops, added to intense pain (2, 5), finally ending up with numbness due to destruction of nerve endings, metastatic infections and toxic syndrome, with tachycardia, respiratory distress or shock lung, oliguria, confusion, acidosis, raised CK and falls in platelet count, albumin, calcium, iron and clotting factors, leading to disseminated intravascular coagulation (1, 3, 11).

Diagnosis is made by bacteriological examination of the exudate and cultures, serological analysis of anti-Dnase and anti-hyaluronidase (ASLO is weak and of no use for diagnosing this disease (3)) and surgical exploration, by demonstrating that a blunt instrument can easily be passed along the planes of the necrotic tissues (3). However, clinical diagnosis (the identification of the skin lesions and the changes in the patient’s general condition) is the most important element, since it is made earlier.

Treatment is a combined antibiotic therapy (clindamycin + penicillin G benzathine), complete debridement of the necrotic tissue and maintaining of haemodynamic status (3, 7, 10, 11). Immunoglobulin therapy is experimental and the use of hyperbaric oxygen has not been proven.

Nevertheless, despite the intensive treatment and aggressive surgery, mortality rates are high (between 20% and 70%, depending on the series consulted (5, 10), especially if debridement is delayed, there are serious analytical signs, such as leukocytes above 30,000 and creatinine over 2, or the patient has underlying heart disease.

Necrotizing fasciitis is a rare and aggressive condition, which can occur after surgical interventions, including cosmetic surgery. Severe infections have been reported following cosmetic surgery interventions, such as excisions, biopsies, grafts, peelings, skin abrasions, resurfacing, liposuctions, blepharoplasties and infiltrations (7). Various reports have been found in the literature of cases of necrotizing fasciitis following cosmetic surgery interventions, with liposuction standing out among them (2, 4, 5, 10). This is considered to be a safe intervention (7) and has become increasingly more popular (10). Patients should be suitably informed of the possible complications, including this serious infection (4, 7). Likewise, in order for it to be identified rapidly, healthcare professionals must familiarise themselves with the clinical signs and symptoms (7), since only early diagnosis and aggressive treatment reduce the high mortality rates (5, 9). Having said that, prevention is the determining factor (8) since the survivors still suffer serious cosmetic sequelae (2, 14, 10), complications all of which are unacceptable after an elective cosmetic surgical procedure. 

Address for correspondence:

Irene Gonzáles Alaňa

C/ Adriano VI 2, 4° D

01008 Vitoria

Spain

E-mail: irenemed2000@yahoo.com