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Patient Stories
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A 9-day-old neonate presented with high fever, moaning, and slightly indurated swelling with bluish discoloration on the back (Figure 106-1). Within 12 hours, there was vesiculation and purplish discoloration. The infant was diagnosed with necrotizing fasciitis and surgery was consulted immediately. The first surgical exploration and débridement and shows the underlying muscle and necrotic borders. Both blood and tissue cultures grew Staphylococcus aureus. Multiple surgical explorations and débridement were performed followed by skin grafting during recovery. The infant survived with scarring but no other sequelae.

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FIGURE 106-1

A. A 9-day-old neonate presented with high fever, moaning, and slightly indurated swelling with bluish discoloration on the back. Within 12 hours, there was vesiculation and purplish discoloration. B. This photograph was taken 8 hours following the first surgical exploration and débridement and shows the underlying muscle and necrotic borders. C. Close-up showing necrotic borders and pus over the underlying muscle. Both blood and tissue cultures grew Staphylococcus aureus. D. Multiple surgical explorations and débridement were performed followed by skin grafting during recovery. (Used with permission from Shah BR, Lucchesi M. The Atlas of Pediatric Emergency Medicine, McGraw-Hill, 2006, p. 87.)

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A 16-year-old female presented with necrotizing fasciitis of the left gluteal region following an intramuscular injection received in rural India. She was febrile and in septic shock. The entire left gluteal region had full thickness necrosis and was emitting a foul odor. The skin was violaceous with purple bullae and areas of exfoliation. Previous attempts at incision and drainage were not helpful. She was treated with intravenous fluids, antibiotics and full-thickness extensive surgical debridement in the operating room. She became afebrile and hemodynamically stable. Her subsequent treatment consisted of negative pressure wound therapy followed by skin grafting. She survived with scarring and contour deformities but no other sequelae (Figure 106-2).

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FIGURE 106-2

A. Necrotizing fasciitis of the left gluteal region following an intramuscular injection received in rural India. This 16-year-old female was febrile and in septic shock. The entire left gluteal region had full thickness necrosis and was emitting a foul odor. The skin was violaceous with purple bullae and areas of exfoliation. Previous attempts at incision and drainage were not helpful. B. Healing with scarring and contour deformities. Treatment consisted of intravenous antibiotics, full-thickness extensive surgical debridement, negative pressure wound therapy followed by skin grafting. (Used with permission from Dr. N. Jithendran and http://diabeticfootsalvage.blogspot.in/2012/11/post-intramuscular-injection-soft.html.)

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Introduction
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Necrotizing fasciitis (NF) is a rapidly progressive infection of the deep fascia, with necrosis of the subcutaneous tissues. In children, it usually occurs after surgery, trauma, or varicella infection. Patients have erythema and pain disproportionate to the physical findings. Immediate surgical debridement and antibiotic therapy ...

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