Periorbital Necrotizing Fasciitis in a Child Without a Predisposing Factor

To the Editors: Periorbital necrotizing fasciitis (PONF) is a rapidly progressive and severe soft tissue infection with a relatively low mortality rate of approximately 6%–14%, and when monomicrobial and most commonly caused by Group A beta-hemolytic streptococcus (Streptococcus pyogenes).1–3 Here, we present a case of PONF caused by S. pyogenes in a 2-year-old child without any identifiable predisposing factors who was treated without sequelae. A previously healthy, fully vaccinated, 2-year-old male patient was admitted with complaints of fever and swelling, redness in the left eye that started in the morning. There was no history of predisposing factors. On his first examination, he had left periorbital edema, erythema and ecchymosis with yellow-crusted papular lesions in the skin consistent with bullous impetigo (Fig. 1A, B). Radiologic findings were compatible with preseptal cellulitis. Meropenem was started. Due to the progression of swelling, redness, and ecchymosis around the eye within hours, elevated acute phase reactants (C-reactive protein: 189 mg/L and procalcitonin: >92 µg/L) and prolonged prothrombin time (17 sn) and activated partial thromboplastin time (39 sn), vancomycin, clindamycin, and intravenous immunoglobulin (1 g per kg per day on the first day) were started in the suspicion of PONF and streptococcal toxic shock syndrome. Surgical drainage and fasciotomy were performed by ophthalmologists as it continued to deteriorate clinically and a progressive increase in the Laboratory Risk Indicator for Necrotizing Fasciitis scores (Fig. 1C–E and Table 1). Due to the risk of progression to streptococcal toxic shock syndrome, intravenous immunoglobulin was given for 3 days (0.5 per kilogram per day on the 2nd and 3rd days). When abscess culture revealed S. Pyogenes, treatment was de-escalated to ceftriaxone plus clindamycin. Follow-up was performed by placing a drain, irrigating with hypochlorous acid, and dressing with bacitracin, neomycin, and cefazolin every 2 hours. Then drains were removed, irrigating and dressing period were extended according to clinical improvement. The histopathological examination of surgical sample demonstrated dense chronic active inflammation with focal necrosis. Anti-toxin therapy was discontinued on 10 days and others on 21 days after clinical and radiological recovery (Fig. 2). He is under follow-up in the outpatient clinic of Ophthalmology and Pediatric Infectious Diseases. TABLE 1. - LRINEC Score Scale by Hours CRP (0–5 mg/L) WBC (4–10 ×10³/µL) HGB (11–16 g/dL) Na (136–146 mmol/L) Cr (0.26–0.77 mg/dL) Glu (60–100 mg/dL) LRINEC Score At Admission 33 29.5 10.8 136 0.35 131 4 After 8 hours 189 19.8 8.6 136 0.24 78 7 After 16 hours 239 20.2 8.8 134 0.25 98 9 After surgery 205 11.5 10.2 142 0.17 111 6 Cr indicates creatinine; CRP, C-reactive protein; Glu, glucose; HGB, hemoglobin; LRINEC, Laboratory Risk Indicator for Necrotizing Fasciitis; Na, sodium; WBC, white blood cell;. FIGURE 1.: A, Ten hours before the admission. B, At admission. C, Three to 4 hours after the admission. D, Twelve hours after the admission. E, Twenty-four hours after the admission.FIGURE 2.: Before discharge.For the eyelids tend to be resistant to the infection due to the anatomical structures, PONF is a rare but severe infection. In the literature, the majority of cases are in adults, less common in children.4 Although in many cases there is a predisposing factor such as odontogenic infections, surgical procedures, sinusitis, skin and soft tissue infections, trauma, insect bites, it can also occur without a predisposing factor.3 This case is to emphasize the importance of maintaining a high level of clinical suspicion in pediatric patients presenting with periorbital swelling and a rapidly deteriorating clinical course, and highlight the critical role of early diagnosis, appropriate antibiotic therapy and timely surgical intervention. In conclusion, PONF should be considered as a differential diagnosis in children presenting with periorbital swelling in the presence of a rapidly progressive course.