|Year : 2022 | Volume
| Issue : 1 | Page : 45-47
Necrotizing fasciitis following a monkey bite
Department of General Surgery, Dr. Mehta Hospital Global Campus, Chennai, Tamil Nadu, India
|Date of Submission||07-Jul-2021|
|Date of Decision||29-Oct-2021|
|Date of Acceptance||05-Nov-2021|
|Date of Web Publication||13-Jan-2022|
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Necrotizing fasciitis (NF) is rapidly spreading bacterial infection of a facial plane. It has a higher mortality rate in patients with diabetes and immunocompromised state. The initial presentation mimics cellulitis and most of the cases are misdiagnosed. Delayed diagnosis and treatment increase mortality by nearly 100%. Our case developed NF with septic shock following a monkey bite. The patient underwent prompt fasciotomy along with extensive wound debridement. Later, the patient underwent secondary suturing with a skin graft for wound cover. NF following money bite is not reported in the literature till now. Hence, early diagnosis and prompt surgical debridement in monkey bites will reduce the incidence of mortality due to NF.
Keywords: Fasciotomy, monkey bite, necrotizing fasciitis, septic shock, wound infection
|How to cite this article:|
Pandiaraja J. Necrotizing fasciitis following a monkey bite. Apollo Med 2022;19:45-7
| Introduction|| |
Necrotizing fasciitis (NF) is rapidly spreading bacterial infection of a facial plane. The mortality of NF is around 30% in the general population. It has a higher mortality rate in patients with diabetes and immunocompromised state. It is more common on extremities, but there are reports of NF involving the head-and-neck region and abdomen.
There are three types of NF. Type 1 is polymicrobial (Gram-positive, Gram-negative, and anaerobic) consists of streptococci, staphylococci, enterococci, etc., type 2 is monomicrobial mainly consists of group A streptococci, and type 3 is due to Vibro species or Methicilin resistant Staphylococcus aureus.
| Case Report|| |
A 47-year-old male, nondiabetic individual presented in a state of septic shock along with a swollen right leg. He had a history of a monkey bite on the right leg before 1 week. Now patient presented with swollen right leg along with foul-smelling discharge from the bite site for the past 5 days [Figure 1]. He had a history of fever with chills and rigors for the past 2 days. He is not a known case of diabetes, hypertension, tuberculosis, ischemic heart disease, and retroviral infection. He is not on any immunosuppression drugs. He never consumes alcohol. There was no history of previous surgery.
|Figure 1: Preoperative image shows monkey bite mark sites along with edema and erythema of right lower limb|
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On examination, the patient was febrile (temperature-103F), blood pressure-90/50 mmHg, pulse rate-130/mins, respiratory rate-31/mins. Local examination showed swollen right leg with the erythema. There were three monkey bite marks with foul-smelling discharge. There was local warmth and tenderness. He was resuscitated with inotropic and intravenous fluids.
The blood investigations showed, hemoglobin-8.0 g/dl, total count-42,000 cells/cumm, platelet-1.3 lakhs, urea-44 mg/dl, creatinine-1.4 mg/dl, random blood sugar-102 mg/dl, HbA1c-5.5, HIV 1 and 2-negative, HbsAg-non reactive, hepatitis C Virus -non reactive.
The patient was taken for the emergency fasciotomy along with wound debridement under general anesthesia. Necrotic tissue along with slough was excised extensively [Figure 2]. Pus was taken for culture and sensitivity. The necrosis involved the skin, subcutaneous tissue, and fascia. The patient was managed in an intensive care unit under an intensivist following surgery. The patient was started on empirical antibiotics with a calculated dose of cefoperazone with sulbactam 1.5-g i. v bid and metronidazole 500 mg i. v TDS. Aminoglycosides were avoided due to increased renal parameters. The patient's condition improved the following debridement and resuscitation. On the postoperative day 6, the patient was shifted toward. The patient was discharged on day 14 and advised for local dressing. Patient wound improving with good granulation tissue without evidence of wound infection [Figure 3]. The patient underwent wound closure with skin grafting for the raw area [Figure 4]. He was on following up for more than 3 years without any complications.
|Figure 2: Intraoperative image shows necrotic tissue along with purulent discharge from the right lower limb|
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|Figure 3: Intraoperative image before secondary suturing with skin grafting shows well-formed granulation tissue|
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|Figure 4: Postoperative image of right lower limb following secondary suturing with skin grafting|
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| Discussion|| |
NF type 1 is most commonly associated with diabetes, prolonged steroid intake, patient on immunosuppression, chronic renal failure, obesity, malnutrition, retroviral positive, intravenous drug abuse, peripheral vascular disease, associated malignancy, gout, congestive heart failure, chronic obstructive pulmonary disease, and chronic alcoholic. But NF 2 can occur even in the young healthy individual without any co-morbid conditions. Type 1NF is more common following abdominal and perineal surgery whereas type 2 is more common following minor trauma and animal bite [Table 1].
The pathogenic organism gets entry through the skin lesion, insect bite, or external injury. After gaining access, the virulent bacteria bind to the muscle using selective cell surface protein. Blunt and penetrating trauma, postsurgical site, following delivery, following burns, following an insect bite, following tattooing, and invasive procedure are the provocation factors for NF.
Most early cases of NF mimic cellulitis due to the presence of erythema, edema, local warmth, and tenderness. Only advanced cases show the clinical features of NF. Early diagnosis of NF and prompt treatment saves the patient life. There are lots of case reports of NF diagnosed in the late stage and patient life could not be saved.
There are no laboratory parameters that can exactly diagnose NF. So, it is always necessary to have a high index of suspicion based on risk factors, history of insect bite or history of animal bite, rapidly progressive systemic sepsis. If clinical features are out of proportion of pain, one should consider the differential diagnosis of NF.
Early detection and extensive debridement along with fasciotomy are the cornerstones of the management of NF. Since when the debridement is done within 12 h of the onset of symptoms, the mortality rate falls <6%, whereas when the debridement is done after 24 h, the mortality rate is more than 30%.
Broad-spectrum antibiotics should be started as soon as a diagnosis is made. Selective antibiotics can be initiated based on culture and sensitivity reports. Antibiotics alone are not sufficient unless we do extensive surgical debridement. Hence do not wait for antibiotics to act unless there is surgical debridement. Most of the cases required multiple wound debridement followed by reconstruction using grafting or flap cover. A study conducted by Shah et al. showed increased white blood cell count, hyponatremia, hypoalbuminemia, anemia, and increased renal parameters were considered poor prognostic factors in a patient with necrotizing soft-tissue infections.
Our patient is a nondiabetic person who developed NF following a monkey bite. Anya Romanoff et al. reported a case of NF following perforated acute appendicitis, which was managed by laparotomy with abdominal wall debridement. Sikora et al. reported a case of NF following a human bite. Anca M. Avram reported a case of NF following an insect bite (spider). He reported a high incidence of mortality in diabetic and obese patients even with early aggressive debridement and higher antibiotics. Das et al. reported a case of NF following a dog bite. Makhdoomi et al. reported a case of NF following cesarean section.
Septic shock, renal failure, coagulation failure, arrhythmia, and multi organs failure are the common causes of mortality in NF. The patient who recovered from NF might have prolonged morbidity due to repeated reconstructive surgery, skin graft or flap, and limb loss following amputation.
Take home message:
- NF can occur following a monkey bite
- Early diagnosis and prompt surgical debridement along with fasciotomy will save the patient life
- There are no specific laboratory investigations that are 100% diagnostic of NF
- A high index of suspicion based on risk factors, history of insect bite, or history of animal bite is needed for prompt intervention.
Limitation and strength of the study
Since it is a case report, prospective or retrospective studies are needed for further opinion.
Written informed consent has been obtained from the patient.
| Conclusion|| |
NF can occur following a monkey bite. Initial presentation of NF mimics cellulitis. Early diagnosis and prompt surgical debridement along with fasciotomy will save the patient life. There are no specific laboratory investigations that are 100% diagnostic of NF. Hence, it is always necessary to have a high index of suspicion based on risk factors, history of insect bite or history of animal bite, rapidly progressive systemic sepsis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]