‘Stalled’ periocular necrotising fasciitis: early effective treatment or host genetic determinants?

Abstract

Background Necrotising fasciitis (NF) is a devastating disease with considerable mortality and morbidity, and early aggressive surgical debridement of devitalised necrotic tissues has traditionally been advocated. Methods We describe three patients who were referred from other units several weeks after developing periocular necrotising fasciitis; in all the three, the disease had been managed medically without surgical debridement, with apparent 'stalling' of the inflammatory process despite persistent necrotic periocular tissue. Results Following 'elective debridement' of the devitalised tissues and reconstruction with local flaps, all achieved a satisfactory aesthetic result. Discussion The role of host genetic determinants, polarised cytokine responses, and early, effective medical treatment in patients with atypical 'disease phenotypes' in NF are discussed.

A case of periorbital necrotizing fasciitis rapidly progressing to severe multiorgan failure

“…While the risk of septic shock in PNF is about 20%, it is twice as high in NF elsewhere in the body [ 2 ]. To further illustrate the presumed difference in severity between PNF and NF, some case reports describe successful management of PNF with medical management alone [ 2 , 8 , 9 ]. Despite the apparent milder nature of PNF, as demonstrated by the described above case, it is associated with serious complications and should be managed as a life-threatening condition.…”

Periocular necrotising fasciitis: a multicentre case series

“…Several reasons probably underlie the better prognosis for PONF: (a) earlier presentation , PONF arising in the most visually evident area, leading to short period of symptoms; despite the visual evidence, some patients in this series were not identified as being PONF until some days after presentation; (b) better antibiotic penetration , the very rich subcutaneous vasculature of the periocular tissues facilitating antibiotic delivery into affected non-necrotic tissues, and this might have allowed disease containment in a significant number (7/29) of cases. Three other cases of non-surgically treated PONF have recently been described12 13; (c) orbital septal integrity , the orbital septum appearing to retard posterior spread of PONF: infection appears to prefer spread along the superficial planes across the face, and thereby might limit the space for potential necrotic cavity formation.…”

“…Periocular necrotising fasciitis (PONF) is rare, with a recent study estimating a UK incidence of 0.24 cases per million per annum 1. Most experience of PONF, based on case reports and three small case series,2–11 indicates that PONF has a better prognosis than the condition elsewhere in the body, and there are reports of success with medical treatment alone 12 13. We present a series of patients with PONF to examine the clinical features, microbiological characteristics, disease course, management and outcomes for this rare condition.…”

Periocular necrotizing soft tissue infection in Greater Copenhagen

“…However, several studies indicate that the prognosis of PNF is considerably better than the overall NF prognosis (Mutamba et al. ; Rajak et al. ).…”

“…Early diagnosis and treatment are important in order to avoid mortality and major morbidity such as permanent visual loss (Amrith et al 2013). However, several studies indicate that the prognosis of PNF is considerably better than the overall NF prognosis (Mutamba et al 2013;Rajak et al 2016). Treatment options include antibiotics, surgical debridement, intravenous immunoglobulin (IVIg) treatment and hyperbaric oxygen therapy (HBO) (Saenz et al 2009;Proia 2018).…”