(From the November 2013 Issue of PediatricsOnline)
Necrotizing fasciitis, commonly known as a “flesh-eating” bacterial infection, may not always feature the standard clinical warning signs in children as it does in adult populations, according to a new study by a team from Nationwide Children’s Hospital. The findings point to the need for broader diagnostic criteria for pediatric patients.
In the first known study of necrotizing fasciitis of the extremities in children, researchers reviewed the medical charts of 13 patients to analyze risk factors and develop clinical guidelines for laboratory workup and identification of the infection in the pediatric population. The analysis revealed that symptoms varied considerably, says Kevin E. Klingele, MD, chief of the Department of Orthopedics and senior author of the study.
“Although many of the common physical exam findings may be present, there is significant variability in the exam, radiographic and laboratory evaluation in these patients,” says Dr. Klingele. “A high index of suspicion should prompt aggressive management as there is no true, definitive means of diagnosis prior to surgical intervention.”
Published in a recent issue of the journal Orthopedics, the study found that symptoms common in adult and pediatric infections of the head and trunk, such as bullae, fluctuance, ecchymosis, fever and average platelet counts, were not consistently found in children with necrotizing fasciitis of the extremities. Only two patients had the “classic” sign of subcutaneous air on imaging tests.
The majority of patients were admitted with a diagnosis of cellulitis, and only one patient tested positive on an initial blood culture. Fever, elevated white blood cell count, erythrocyte sedimentation rate and C-reactive protein values were statistically associated with a surgically confirmed diagnosis of necrotizing fasciitis, but severity of these symptoms prior to surgery was highly variable.
All patients in the study underwent surgery within 24 hours of presentation and required multiple debridements, and nearly all patients’ bacterial strains were susceptible to the antibiotic clindamycin. No amputations and no deaths occurred in the patient population.
“Children who do not meet the standard criteria for this type of tissue infection should still be closely monitored,” says Dr. Klingele. “Aggressive management may help prevent amputation and mortality.”
Tancevski A, Bono K, Willis L, Klingele K. Necrotizing Fasciitis in a Pediatric Orthopedic Population. Orthopedics. 2013 June, 36(6): e741-745.