Cranial fasciitis of childhood

Cranial fasciitis of childhood is a benign lesion occurring superficial to or involving the cranial bones of children at a median age of 18 months, with a male sex predilection of 2:1. It is histologically described as a well-circumscribed, loose proliferation of stellate to spindle-shaped fibroblasts in a myxoid background with foci of hemorrhage and hyalinization. Mitotic figures, increased cellularity, and cellular immaturity may be seen. The treatment of choice is excisional biopsy, since the lesion is not known to recur. It is important that the pathologist and surgeon alike be able to differentiate this benign condition from other lesions because of the clinically threatening presentation of cranial fasciitis.     

High cytokine levels at admission are associated with fatal outcome in patients with necrotizing fasciitis

We evaluated in a blinded fashion the cytokine profiles of patients with suspected necrotizing fasciitis. In 15 out of 20 patients, the diagnosis of necrotizing fasciitis was established; five patients had cellulitis. Eighteen of the 20 patients were i.v. drug users. Five of the 15 patients with necrotizing fasciitis died (33%). On admission, serum levels for interleukin-1beta (IL-1beta), IL-1-receptor antagonist (IL-1Ra), IL-18 and interferon-gamma (IFNgamma) as well as white blood cells (WBC) were significantly elevated in patients with fatal outcome compared to survivors with necrotizing fasciitis. IL-1Ra and WBC levels were also higher than in patients with cellulitis. No differences were observed between patients groups for IL-6 and IL-8. In summary, significantly elevated levels of proinflammatory cytokines and particularly IL-1Ra are associated with fatal outcome in patients with necrotizing fasciitis. The measurement of proinflammatory cytokines and IL-1Ra may help to establish early diagnosis of life-threatening necrotizing fasciitis and thus to initiate aggressive treatment.     

Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans

Learning Objectives: After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes.Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.     

Clinical experience with 20 cases of group A streptococcus necrotizing fasciitis and myonecrosis: 1995 to 1997.

During the last decade, there has been a dramatic resurgence of necrotizing fasciitis caused by group A streptococcal disease with mortality rates from 43 to 58 percent. The objective of this study was to review recent clinical experience regarding the diagnosis and management of streptococcal necrotizing fasciitis, including the use of high-dose intravenous immunoglobulin. From April of 1995 to December of 1997, 20 consecutive adult patients meeting clinical and/or histopathologic criteria for streptococcal necrotizing fasciitis were identified in the Toronto area. Of those, 16 (80 percent) were treated with > or = 1 mg/kg of intravenous immunoglobulin. Fourteen men and 6 women ranging in age from 33 to 89 were identified (median age 55.5 years). Sixteen patients (80 percent) with necrotizing fasciitis survived. Ten patients had necrotizing fasciitis alone, none of whom died. Eight patients were identified with myonecrosis and necrotizing fasciitis, three of whom died. The case fatality rate of all patients who received intravenous immunoglobulin was 19 percent (3 of 16) and was not statistically significantly different (p = 1.0) from the case fatality rate of 25 percent (1 of 4) in those patients who did not receive intravenous immunoglobulin. A total of seven patients (35 percent) were diagnosed as having a cause for their signs and symptoms other than necrotizing fasciitis when they initially presented to a physician; one of these patients died. There was no correlation with the M type or the streptococcal pyrogenic exotoxin genotype and outcome.     

Focus: Rare Disease: Necrotizing Fasciitis: Association with Pregnancy-related Risk Factors Early in Life

Background: Pregnancy-related risk factors for necrotizing fasciitis are poorly understood. We investigated pregnancy-related characteristics associated with the long-term risk of developing necrotizing fasciitis, a rare life-threatening infectious disease. Methods: We analyzed a longitudinal cohort of 1,344,996 parous women in Quebec, Canada between 1989 and 2020. The main exposure measures included complications of pregnancy such as gestational diabetes, preterm delivery, metabolic disorder, and other maternal characteristics. We followed the women over time to identify future hospitalizations for necrotizing fasciitis up to three decades after delivery. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the association of pregnancy characteristics with risk of necrotizing fasciitis in time-varying Cox proportional hazards regression models. Results: A total of 420 women were hospitalized for necrotizing fasciitis during follow-up, including 83 (19.8%) with diabetes-related necrotizing fasciitis. The incidence of necrotizing fasciitis was elevated for women with gestational diabetes (2.9 per 100,000 person-years), preterm delivery (3.2 per 100,000 person-years), and metabolic disorders (5.4 per 100,000 person-years), compared with no pregnancy complication (1.1 per 100,000 person-years). Compared with no pregnancy complication, gestational diabetes was associated with 1.87 times the risk (95% CI 1.38-2.53), preterm delivery with 2.10 times the risk (95% CI 1.65-2.66), and metabolic disorder with 3.72 times the risk (95% CI 2.92-4.74) of developing necrotizing fasciitis over time. Pregnancy complications were more strongly associated with the risk of necrotizing fasciitis 5 years or more after delivery. Conclusions: Complications of pregnancy may be associated with the long-term risk of necrotizing fasciitis in women.     

La gangrène des organes génitaux externes de I’homme: Facteurs de risque et de pronostic

The objective of this study, based on 20 cases of necrotizing fasciitis of the male genitalia, is to identify the risk factors and prognostic factors of this disease. Most cases of necrotizing fasciitis of the male genitalia occurred in elderly men with a poor socio-economic level including 9 diabetics. There was no identifiable cause in 8 cases (Fournier’s gangrene). All patients underwent surgical excision and systematic antibiotic therapy. This series comprised 5 deaths (25%) in patients over the age of 69 years with extensive lesions and a very poor general state on admission. The outcome of survivors was favourable after a prolonged hospital stay (mean stay: 1 month). The clinical context therefore appears to play an essential role in the development of this disease and its subsequent prognosis, which could be improved by rapid and appropriate prevention and treatment.     

Twin fetus in fetu in a child: a case report and review of the literature

Introduction

Necrotizing fasciitis is a rare condition with a mortality rate of around 34%. It can be mono- or polymicrobial in origin. Monomicrobial infections are usually due to group A streptococcus and their incidence is on the rise. They normally occur in healthy individuals with a history of trauma, surgery or intravenous drug use. Post-operative necrotizing fasciitis is rare but accounts for 9 to 28% of all necrotizing fasciitis. The incidence of wound infection following saphenofemoral junction ligation and vein stripping is said to be less than 3%, although this complication is probably under-reported. We describe a case of group A streptococcus necrotizing fasciitis following saphenofemoral junction ligation and vein stripping.

Case Presentation

A 39-year-old woman presented three days following a left sided saphenofemoral junction ligation with long saphenous vein stripping at another institution. She had a three day history of fever, rigors and swelling of the left leg. She was pyrexial and shocked. She had a very tender, swollen left groin and thigh, with a small blister anteriorly and was in acute renal failure. She was prescribed intravenous penicillin and diagnosed with necrotizing fasciitis. She underwent extensive debridement of her left thigh and was commenced on clindamycin and imipenem. Post-operatively, she required ventilatory and inotropic support with continuous veno-venous haemofiltration. An examination 12 hours after surgery showed no requirement for further debridement. A group A streptococcus, sensitive to penicillin, was isolated from the debrided tissue. A vacuum assisted closure device was fitted to the clean thigh wound on day four and split-skin-grafting was performed on day eight. On day 13, a wound inspection revealed that more than 90% of the graft had taken. Antibiotics were stopped on day 20 and she was discharged on day 22.

Conclusion

Necrotizing fasciitis is a very serious complication for a relatively minor, elective procedure. To the best of our knowledge, this is the first report in the English-language literature of this complication arising from a standard saphenofemoral junction ligation and vein stripping. It highlights the need to be circumspect when offering patients surgery for non-life-threatening conditions.     

Bilobed fasciocutaneous flap for reconstruction of the posterior neck after necrotizing fasciitis

Necrotizing fasciitis is an aggressive, deep-seated infection of the fascia and subcutaneous fat with necrosis of overlying skin. Eleven cases of necrotizing fasciitis of the posterior neck are reviewed to demonstrate the advantage of using a bilobed fasciocutaneous flap for repair following surgical debridement. Nine men and two women aged 40 to 65 years (mean age, 54.8 years) presented for reconstruction from April of 1999 to March of 2003. The blood supply of the bilobed fasciocutaneous flap originates from a constant row of musculocutaneous perforators of posterior intercostal arteries. The technique enabled regional reconstruction, conserved tissues, and provided satisfactory aesthetic results.     

Nodular fasciitis: diagnosis by fine needle aspiration biopsy

OBJECTIVE: To describe the cytomorphologic features of nodular fasciitis that differentiate it from schwannoma. STUDY DESIGN: The cytomorphologic features of 10 cases of nodular fasciitis were compared to those of 4 cases of biopsy-proven schwannoma. Aspirate smears were evaluated for cellular cohesion, cell type and stroma. Immunoperoxidase stains were utilized in select cases. RESULTS: The cases of nodular fasciitis exhibited cohesive clusters of epithelioid to spindle-shaped cells in a background of single, intact mesenchymal cells; inflammatory cells; and myxoid stroma. In contrast, schwannomas lacked single, intact cells and inflammation. Schwannoma stroma was also myxoid but appeared more finely fibrillar, and cell clusters were notable for alternating areas of hypercellularity and hypocellularity. Immunoperoxidase stains demonstrated smooth muscle actin reactivity in 5 cases of nodular fasciitis and S-100 in 2 cases of schwannoma. CONCLUSION: Nodular fasciitis can be distinguished from schwannomas on the basis of cytomorphologic features and immunocytochemical profile. Cytologic diagnosis of nodular fasciitis is important since it obviates the need for surgical excision.     

The efficacy of a pneumatic compression device in the treatment of plantar fasciitis

Plantar fasciitis is a common foot disorder that affects more than two million Americans each year. Conservative management of plantar fasciitis is the first line of treatment by the medical specialist who frequently encounters this common foot complaint. In this study, 50 patients with plantar fasciitis of 4 weeks duration but less than 12 weeks were randomized into two groups. One group of 25 patients used the AirHeel (Aircast, Inc.) and the second group of 25 used the 1st Step prefabricated foot insert (Wrymark, Inc). Standardized weight-bearing radiographs were obtained in order to categorize the foot type: normal arch, pes planus, or pes cavus. Patients were initially evaluated and at 12 weeks they returned for a subsequent visit. The contact area of the foot with the AirHeel and 1st Step insert were similar, an increase of 27% and 26%, respectively, over the contact area barefoot. There was a noted difference in force reduction with the two devices. The AirHeel reduced the midstance force by 20.19%, as compared to the 1st Step insert which showed a 1.03% increase in midstance force. Patients with a higher initial pain score seemed to respond better initially to the AirHeel (p = 0.015) than the 1st Step insert (p = 0.035). This study demonstrates the benefits of offloading the foot at midstance with two devices to relieve the discomfort associated with plantar fasciitis. The Aircast AirHeel is a new modality for dynamic, functional treatment of proximal plantar fasciitis.     

Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial

Objective To determine the effectiveness of extracorporeal shock wave therapy compared with placebo in the treatment of chronic plantar fasciitis.Design Randomised, blinded, multicentre trial with parallel group design.Setting Nine hospitals and one outpatient clinic in Germany.Participants 272 patients with chronic plantar fasciitis recalcitrant to conservative therapy for at least six months: 135 patients were allocated extracorporeal shock wave therapy and 137 were allocated placebo.Main outcome measures Primary end point was the success rate 12 weeks after intervention based on the Roles and Maudsley score. Secondary end points encompassed subjective pain ratings and walking ability up to a year after the last intervention.Results The primary end point could be assessed in 94% (n=256) of patients. The success rate 12 weeks after intervention was 34% (n=43) in the extracorporeal shock wave therapy group and 30% (n=39) in the placebo group (95% confidence interval - 8.0% to 15.1%). No difference was found in the secondary end points. Few side effects were reported.Conclusions Extracorporeal shock wave therapy is ineffective in the treatment of chronic plantar fasciitis.     

Successful Treatment of a Necrotizing Fasciitis Patient Caused by Mucor indicus with Amphotericin B and Skin Grafting

Cutaneous mucormycosis, an uncommon disease caused by Mucorales, predominantly occurs in immunocompromised host. The present case is a primary cutaneous mucormycosis due to Mucor indicus in an immunocompetent individual. It is with the features of necrotizing fasciitis over the right pretibial area. We are presenting this case owing to its rarity and the successful treatment with amphotericin B and skin grafting.     

Recent Observations on Mesenchymal Tumours in Adults and Children

Recognition of the types and characteristics of mesenchymal tumours is important, since each type has biological features peculiar to itself that govern its growth and behaviour and it is essential to know these if treatment is to be effectual. Because many differentiated cell types are capable of acting as facultative fibroblasts, histological diagnosis is often in error. It has been found that no matter how bizarre a tumour may appear, if explanted in vitro, the cells will betray their true nature. By this means the various mesenchymal tumour types have been classified, many examples collected and followed up and their biological potentialities recorded. In more recent studies these uncommon tumours in children have been studied and many of them found to be less malignant than in adults. New varieties of mesenchymal tumours have been discovered in recent years, such as pseudosarcomatous fasciitis, elastofibroma dorsi, and bizarre variants of smooth muscle tumour.     

Nodular fasciitis of the breast: report of a case initially diagnosed by fine needle aspiration cytology

BACKGROUND: Nodular fasciitis is a rare benign pseudosarcomatous proliferation of fibroblasts in the breast, in which the clinical examination and mammographic findings may closely mimic mammary carcinoma. CASE: A case of nodular fasciitis was diagnosed by fine needle aspiration. A 15-year-old girl was admitted to our hospital with a recently noticed, rapidly growing mass in the right breast. The aspirate contained cohesive groups of fusiform cells with elongated and oval nuclei, regular nuclear membranes and inconspicuous nucleoli, intermingled with scattered lymphocytes, red blood cells and characteristic granular background substance. A cytologic diagnosis of nodular fasciitis was made and confirmed histologically. CONCLUSION: Mammary nodular fasciitis is often clinically suspicious for carcinoma and rarely diagnosed by fine needle aspiration cytology. A literature search yielded only five reported cases. The cytologic diagnosis of this entity helps to choose the correct surgical procedure, preventing psychological trauma to the patient.     

内镜下治疗跟骨骨刺合并跖腱膜炎所致跟骨痛的临床应用

目的:介绍和分析内镜下治疗跟骨骨刺合并跖腱膜炎所致跟骨痛应用。方法:对2011.10-2014.10来我院就诊的共计67例跟骨骨刺合并跖腱膜炎所致跟骨痛的资料进行分析包括患者术前与术后3月、6月及12月VAS(Visual Analogue Scale)疼痛评分,X线或MRI等影像学资料及和AOFAS(the American Orthopedic Foot and Ankle Society)足踝标准及并发症等指标。结果:患者均接受了至少12个月随访,患者在术后(3,6,12月)的VAS评分及AOFAS评分较术前均有显著改善和提高(P0.05)。影像资料显示:骨刺未见明显复发。1例患者出现皮肤浅层感染,处理后好转,余无明显并发症出现。结论:内镜下治疗跟骨骨刺合并跖腱膜炎对于跟骨痛有较好的疗效。     

Fascitis necrotizante por Saksenaea vasiformis en una paciente inmunocompetente tras un accidente de tráfico

BackgroundCutaneous mucormycosis (zygomycosis), with subcutaneous spreading and dissemination, in immunocompetent patients is an uncommon disease caused by species belonging to the fungal genera Apophysomyces, Rhizopus and Saksenaea, among others.Case reportA case of necrotising fasciitis by Saksenaea vasiformis in an immunocompetent woman is described. The infection was acquired through a car accident resulting in multiple injuries affecting mainly her right arm. After the surgical reduction of fractures, skin lesions worsened and led to necrosis. The patient quickly developed a severe necrotising fasciitis with negative cultures at first. Despite the extensive surgical debridement and the aggressive antifungal treatment, the patient died. The histopathological study showed a fungal infection due to a fungus belonging to the Mucorales order, which was confirmed by culturing the clinical sample on Sabouraud agar, and identifying the species by cultures on Czapek-Dox agar, and sequencing of the ITS region of the ribosomal DNA.ConclusionsThis case confirm the presence of this fungus in Spain, the value of histopathology for the mucormycosis diagnosis, as well as the need to perform special cultures to facilitate their isolation and identification to the species level by the combined use of Czapek-Dox agar and sequencing of the ITS region.     

Hospital admissions for skin and soft tissue infections in a population with endemic scabies: A prospective study in Fiji, 2018–2019

Scabies is an important predisposing factor for impetigo but its role in more serious skin and soft tissue infections (SSTIs) is not well understood. Information is limited on incidence of SSTIs in the presence of endemic scabies. We conducted a prospective study of hospital admissions for SSTIs in the Northern Division of Fiji (population: 131,914). Prospective surveillance for admissions with impetigo, abscess, cellulitis, wound infection, pyomyositis, necrotizing fasciitis, infected scabies, and crusted scabies was conducted at the Division’s referral hospital between 2018 to 2019. Information was collected on demographic characteristics, clinical features, microbiology, treatment and outcomes. Over the study period, 788 SSTI admissions were recorded corresponding to a population incidence 647 per 100,000 person-years (95%CI 571–660). Incidence was highest at the extremes of age with peak incidence in children aged <5 years (908 per 100,000) and those aged ≥65 years (1127 per 100,000). Incidence was 1.7 times higher among the Indigenous Fijian population (753 per 100,000) compared to other ethnicities (442 per 100,000). Overall case fatality rate was 3.3%, and 10.8% for those aged ≥65 years. Scabies was diagnosed concurrently in 7.6% of all patients and in 24.6% of admitted children <5 years. There is a very high burden of hospital admissions for SSTIs in Fiji compared to high-income settings especially among the youngest, oldest and indigenous population which is concordant with scabies and impetigo distribution in this population. Our findings highlight the need for strategies to reduce the burden of SSTIs in Fiji and similar settings.     

Fine needle aspiration of proliferative fasciitis. A case report

The cytologic findings of a fine needle aspiration (FNA) biopsy from a patient with proliferative fasciitis, a benign, reactive process involving the subcutaneous tissue, are presented. Proliferative fasciitis is defined histologically as a spindle-cell lesion containing basophilic giant cells that resemble ganglion cells; the FNA smears from this patient's lesion were cellular and contained spindle cells as well as numerous large cells with abundant cytoplasm, one to two eccentric nuclei and macronucleoli. The large cells seen on the aspiration smears correspond well with the classic ganglionlike cells seen on histologic sections. Care must be taken so that this distinctive lesion is not misdiagnosed as a malignant soft tissue neoplasm.     

Nodular fasciitis and proliferative myositis as variants of one disease entity

The concept of nodular fasciitis and proliferative myositis as variants of the same fibroblastic disorder is supported by intermediary cases, showing simultaneous features thought to be typical of either nodular fasciitis or proliferative myositis. Various other anatomical, pathological and clinical similarities found in this study of 100 cases support such conclusions. 'Ganglion-like' cells were a distinct, but not exclusive, feature of all cases with sole, or only partial, muscle involvement.     

Inhibition of group A streptococcal infection by Melaleuca alternifolia (tea tree) oil concentrate in the murine model

Aims: To investigate the effect of a water‐soluble Melaleuca alternifolia concentrate (MAC) on group A streptococcus (GAS; Streptococcus pyogenes)‐induced necrotizing fasciitis. Methods and Results: MAC pretreatment (1% and 2% v/v) was able to protect mice from GAS infection in an air pouch model. GAS‐induced mouse death and skin injury were inhibited dose dependently by MAC. Administration of MAC at 6 h post‐GAS infection partially delayed mouse death. Surveys of the exudates of the air pouch of MAC‐treated mice revealed that the survival of infiltrating cells was prolonged, the bacteria were eliminated, and the production of inflammatory cytokines was inhibited. MAC could directly inhibit the growth of GAS in vitro, and the minimal inhibitory concentration (MIC) of MAC for GAS was determined as 0·05% v/v using the time‐kill assay. Furthermore, a sub‐MIC dose of MAC not only enhanced the bactericidal activity of RAW264.7 macrophage cells against GAS but also increased susceptibility of GAS for blood clearance. Conclusions: These results suggest that MAC may inhibit GAS‐induced skin damage and mouse death by directly inhibiting GAS growth and enhancing the bactericidal activity of macrophages. Significance and Impact of the Study: Our results provide scientific data on the use of MAC for the treatment of GAS‐induced necrotizing fasciitis in the murine model.