Neonatal necrotizing fasciitis: A report of three cases and review of the literature

Objective. Necrotizing fasciitis (NF) is a predominantly adult disorder, wi th bacterial infection of the soft tissue. In children, it is relatively ra re and has a fulminant course with a high mortality rate. In the neonate, m ost cases of NF are attributable to secondary infection of omphalitis, bala nitis, mammitis, postoperative complications, and fetal monitoring. The obj ective of this communication is to report 3 cases of neonatal NF and provid e a literature review of this disorder. Results. This review yielded 66 cases of neonatal NF. Only 3 cases were pre mature. There was no sex predilection and the condition rarely recurred. Se veral underlying conditions were identified that might have contributed to the development of neonatal NF. These included omphalitis in 47, mammitis i n 5, balanitis in 4, fetal scalp monitoring in 2, necrotizing enterocolitis , immunodeficiency, bullous impetigo, and maternal mastitis in 1 patient ea ch. The most common site of the initial involvement was the abdominal wall (n = 53), followed by the thorax (n = 7), back (n = 2), scalp (n = 2), and extremity (n = 2). The initial skin presentation ranged from minimal rash t o erythema, edema, induration or cellulitis. The lesions subsequently sprea d rapidly. The overlying skin might later develop a violaceous discoloratio n, peau d'orange appearance, bullae, or necrosis. Crepitus was uncommon. Fe ver and tachycardia were frequent but not uniformly present. The leukocyte count of the peripheral blood was usually elevated with a shift to the left . Thrombocytopenia was noted in half of the cases. Hypocalcemia was rarely reported. Of the 53 wound cultures available for bacteriologic evaluation, 39 were polymicrobial, 13 were monomicrobial, and I was sterile, Blood cult ure was positive in only 20 cases (50%). Treatment modalities included the use of antibiotics, supportive care, surgical debridement, and drainage of the affected fascial planes. Two of the 6 cases who received hyperbaric oxy gen therapy died. The overall mortality rate was 59% (39/66). In 12 cases, skin grafting was required because of poor granulation formation or large p ostoperative skin defects among the survivors. Conclusion. Neonatal NF is an uncommon but often fatal bacterial infection of the skin, subcutaneous fat, superficial fascia, and deep fascia. It is c haracterized by marked tissue edema, rapid spread of inflammation, and sign s of systemic toxicity. The wound cultures are predominantly polymicrobial and the location of initial involvement depends on the underlying etiologic factor. High index of suspicion, prompt aggressive surgery, appropriate an tibiotics, and supportive care are the mainstays of management in the newbo rn infant with NF.