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| CASE REPORT |
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| Year : 2016 | Volume
: 12
| Issue : 2 | Page : 72-75 |
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Vulvar necrotizing soft tissue infection in a child: Review of a multi-disciplinary surgical emergency and management in the modern era
Rahul K Patil1, Harshal K Patil2, Prashant Varkey1
1 Department of Plastic Surgery, Jubilee Mission Medical College and Hospital, Thrissur, Kerala, India
2 Department of General Surgery, Jubilee Mission Medical College and Hospital, Thrissur, Kerala, India
| Date of Web Publication | 17-Mar-2017 |
Correspondence Address:
Rahul K Patil
Department of Hand and Micro-vascular Surgery, Khoula Hospital, Al Wuttayya, PC 116, Muscat, Sultanate of Oman
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0794-9316.202463
A case of necrotizing infection of the vulva in a 15-month-old female child has been presented. The case presented multiple problems, from delayed presentation to involvement of critical area and associated issues. The patient sailed through a series of interventions before she could be rehabilitated to her routine but still awaits further reconstructive procedure. Early detection and appropriate intervention of this fulminant disease would help reducing the morbidity.
Keywords: Genital infections, necrotizing soft tissue infection, vulvar infections
How to cite this article:
Patil RK, Patil HK, Varkey P. Vulvar necrotizing soft tissue infection in a child: Review of a multi-disciplinary surgical emergency and management in the modern era. Nigerian J Plast Surg 2016;12:72-5 |
How to cite this URL:
Patil RK, Patil HK, Varkey P. Vulvar necrotizing soft tissue infection in a child: Review of a multi-disciplinary surgical emergency and management in the modern era. Nigerian J Plast Surg [serial online] 2016 [cited 2023 Sep 24];12:72-5. Available from: https://www.njps.org/text.asp?2016/12/2/72/202463 |
| Introduction | |  |
Necrotizing fasciitis (NF) is a rare soft tissue infection,[1] leading to widespread necrosis of subcutaneous tissue and rapid involvement of adjacent tissues and organs. NF carries a high risk of mortality varying from 13% to 50%.[1],[2] Early debridement with excision of all the necrotic tissue is critical in reducing the morbidity and mortality.
This condition is more common in the elderly population, and the predisposing factors are diabetes, obesity, renal diseases, immunosuppression, previous radiation, and surgical trauma.[3],[4] Necrotizing infections are fortunately rare in pediatric population with a very few reports available.[5],[6] General features, risk factors, and outcome in young children are not well described.
This report summarizes a case of vulvar necrotizing infection, highlighting potential risks of missed diagnosis, delayed management, and the outcome following multidisciplinary team management.
| Case Report | | |
A 15-month-old female child was referred to the plastic surgery team by an intensivist, with high-grade fever, low pressures, not responding to iv antibiotics, inotropes, and other supportive measures. The episode started with mild fever 10 days prior and was initially managed at a local hospital. On the 4th day, after noticing swelling in the perineal area, she was referred to our hospital and was admitted under pediatrics for the fever. After initial resuscitation, she was referred to the general surgery team for cellulitis of perineal area. Incision and drainage [Figure 1]a was done by the general surgery team. A urologist was consulted with and suprapubic catheterization (SPC) at the time of drainage. The patient did not respond to the management and subsequently was transferred to the intensive care unit. There was no history of catheterization or any other trauma to the area involved. | Figure 1: (a) Necrotizing infection of vulva involving full thickness of tissues presenting late. (b) Following debridement of the necrotic tissue (inset) and excising the involved fascia. (c) Posteriorly, the disease was extending around the anal canal. As the skin around was precious, as much skin possible was saved while removing all the diseased fascia (can be appreciated from undermined edges)
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She was taken up for urgent debridement, with high-risk consent. The initial procedure included debridement of all the necrotic tissue. In the course, vulva and the perineal skin, fascia from the pubic, and perineal and the upper medial thigh area were debrided. Vaginal mucosa was mostly uninvolved except the distal most part and could be preserved. Posteriorly, the debridement extended into the perianal area [Figure 1]b. The end point of debridement was healthy bleeding tissue bed [Figure 1]c. Tissue cultures from the area reported heavy growth of Pseudomonas aeruginosa mixed with Gram-negative cocci sensitive only to colistin, imipenem, and meropenem. Antibiotics were changed as per culture reports.
Child's general condition improved rapidly and her inotropic support could be discontinued the next day. Colostomy was done for hygiene purpose 48 h later. The child was managed with regular dressings. After the fecal bypass, wound improved rapidly [Figure 2]a and the child was taken up for coverage of the wound. | Figure 2: (a) The defect was ready for flap cover within a week following debridement. (b) Anterolateral thigh pedicled flap was used for cover. (c) The flap was used to cover most of the defect while the donor site and a small part of the defect was covered with skin graft
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In view of the vital area involved and future need for vaginal reconstruction, it was decided to cover the wound with a pedicled anterolateral thigh flap [Figure 2]b. Critical wounds were covered with flap while rest of the wounds were skin grafted [Figure 2]c. The flap settled well, and she was discharged from the hospital with colostomy and SPC 18 days after the initial admission.
Three months following the surgery, SPC reversal was planned by the urology team. To provide them access to the lower end of the urethra, a slit was made in the flap and some de-fattening of the flap was done, the vaginal mucosa was explored, the walls were identified, and the flap skin was sutured to the available vaginal mucosa [Figure 3]. The urologist did cystoscopy and retrograde ureteroscopy to localize the lower end of urethra. Urethral catheterization was done from over the perineum. The child was unable to retain the barium enema at this point, and reversal of colostomy was not possible. | Figure 3: The flap was well settled at 2 months. (a) During the second stage, the flap was slit to allow access to the urologists to create perineal opening and reverse the suprapubic catheterization. The incision was as shown in b. The remaining vaginal mucosa was sutured to the de-fattened flap margins (c). The appearance of perineum after the procedure (d)
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The child returned 6 weeks after the procedure with blocked catheter. The scar had contracted obliterating the vaginal opening. For access to the urethra, the flaps were opened again, and this time, small Z-plasties were used at the upper and lower end to prevent contracture [Figure 4]. | Figure 4: During her follow-up after nearly 5 months after the flap surgery, when the edema had completely settled. Subsequently, the child underwent reversal of colostomy and is now free of catheter
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Four months following the initial surgery, the urinary catheter was discontinued. Parents were taught regarding cleaning and hygiene of the area. She had couple of episodes of urinary retention after that but were managed on outpatient department basis.
Nine months following the initial surgery, the child could retain the barium enema for 15 min. At this stage, it was decided to reverse the colostomy. The child was admitted, and colostomy reversal was done.
| Results | | |
The patient has completed nearly 3 years of follow-up. The vaginal scar has contracted again decreasing the vaginal opening and will need dilatation/reconstruction at a later date. The perineal area will need further attention and surgical procedures for an acceptable esthetic outcome. She can void urine without any problem and did not have any episode of retention again for the past 2 years. Her bowel function is good with maintained fecal continence. She is 4 years plus at the time of writing this article. Her scars have matured but will need revision that will be planned once the overall reconstruction is complete.
| Discussion | | |
NF is a rare and rapidly progressive infection of the superficial fascia and subcutaneous tissue that can be potentially fatal.[5],[6] “Fournier gangrene” is NF of genital area and is more common in diabetic and immunocompromised patients. In children, trunk is most commonly involved.[6] In newborns, NF originates from omphalitis.[7] Mortality rates of this infection are very high, and one study has reported it to be as high as 87.5%.[8] The vulvar NF is fortunately rare, and the exact etiology is unknown.[6],[9]
In pediatric patients, immunosuppressive diseases such as acute lymphoblastic leukemia have been associated with higher risk.[10],[11] Initiating events could range from minor injuries,[12] surgery,[13] or even blunt trauma.[14] The present case did not have any of these predisposing factors.
A high index of suspicion is the key to early diagnosis. Infection usually starts with edema and induration of the area worsening to erythema or discoloration. The rise of temperature and pain are early symptoms and pain is suggestive of underlying tissue necrosis.[15] Gradually the skin develops smooth texture and blisters appear if untreated. It further progresses to necrosis by the 5th or 6th day. Associated crepitus indicates the involvement of anaerobic organisms.[16] Infection spreads along subcutaneous and fascial planes.[17] In the present case, these early signs were missed. Early debridement can prevent progression of the infection. Due to late diagnosis, the present case went into systemic sepsis.
Polybacterial cause of NF is well documented.[18] In the present case, P. aeruginosa mixed with Gram-negative cocci were isolated and were resistant to most of the routine antibiotics. After the adequate debridement, the response to antibiotics changed rapidly. The patient's general condition improved in the 2nd week when the culture isolated enterococcus and pseudomonas but they were moderately sensitive to a few 3rd generation cephalosporins and piperacillin.
Thorough debridement is mainstay of treatment of this potentially life-threatening condition, irrespective of the area involved. Tissue necrosis in the subcutaneous tissue plane is supposed to be due to a compartment like condition, and it should be decompressed extensively. Tissues with doubtful viability especially in the subcutaneous plane should be excised to the live bleeding tissues. Due to the extensive undermining, the skin may undergo further necrosis and usually needs further debridement.
Multidisciplinary management of this serious problem is often inadequately stressed. These patients need the attention and care from the physicians, intensivists, wound management teams, social support nurses, and general/plastic surgical specialists. The involvement of specific areas may need additional interventions from the other specialties as in the present case urology and gastrosurgery team was actively involved in the management. Early consultations, proper evaluation, and prompt intervention would help in reducing the morbidity and mortality and salvaging vital organ damage in this fulminant infectious condition.
Constant counseling by the social nurse regarding the hygiene and self-care, care of the colostomy, and the supra-pubic catheter is all that is required to keep the parents/caretakers motivated with frequent reassurance that at appropriate time these are going to be reversed. The reconstruction of vulva was another matter of concern for the family and needed patient dialog pertaining to all their reservations.
The plan is to reconstruct the vagina at the age of menarche. Local tissues will need readjustment that time for the same.
| Conclusion | | |
Multidisciplinary team approach helped us saving life of this patient and rehabilitating her to some extent though she awaits further reconstruction.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Roberts DB, Hester LL Jr. Progressive synergistic bacterial gangrene arising from abscesses of the vulva and Bartholin's gland duct. Am J Obstet Gynecol 1972;114:285-91.  |
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| 3. | Nolan TE, King LA, Smith RP, Gallup DC. Necrotizing surgical infection and necrotizing fasciitis in obstetric and gynecologic patients. South Med J 1993;86:1363-7. |
| 4. | Roberts DB. Necrotizing fasciitis of the vulva. Am J Obstet Gynecol 1987;157:568-71. |
| 5. | Kosloske AM, Cushing AH, Borden TA, Woodside JR, Klein MD, Kulasinghe HP, et al. Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients. J Pediatr Surg 1981;16:246-51. |
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| 10. | Duncan BW, Adzick NS, deLorimier AA, Longaker MT, Ferrell LD, Zoger S, et al. Necrotizing fasciitis in two children with acute lymphoblastic leukemia. J Pediatr Surg 1992;27:668-71. |
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| 13. | Svensson LG, Brookstone AJ, Wellsted M. Necrotizing fasciitis in contused areas. J Trauma 1985;25:260-2. |
| 14. | Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotizing fasciitis. Importance of roentgenographic studies for soft-tissue gas. JAMA 1979;241:803-6. |
| 15. | Stone DR, Gorbach SL. Necrotizing fasciitis. The changing spectrum. Dermatol Clin 1997;15:213-20. |
| 16. | Rea WJ, Wyrick WJ Jr. Necrotizing fasciitis. Ann Surg 1970;172:957-64. |
| 17. | Feldmeier JJ, Workman WT. The USAF hyperbaric center: A look through the porthole. Mil Med 1983;148:118-21. |
| 18. | Kyong CU, Smith CD, Othersen HB. Necrotizing fasciitis of the abdominal wall as a complication of chickenpox. Pediatr Infect Dis 1985;44:20-421. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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