We report two cases of necrotizing fascitis in the newborn.

Case 1: A 25-day-old full term normally delivered neonate presented with redness and swelling of occipital skin for one day. There was no history of trauma. Local examination revealed an 8 × 7 cm reddish patch over the occipital region. Within 24 hours the scalp showed patches of necrotic skin, discharging fluid and ulcers with slough on its floor. Pus culture grew streptococcus pyogenes while the blood culture was sterile. The infant was treated with parenteral antibiotics, debridement and subsequent skin grafting.

Case 2: An 11-day-old full term caesarean delivered neonate presented to us with necrosis over left occiput, right forearm and both legs. Local examination revealed two necrotic patches - over left occiput measuring 5 × 6 cm. Also a 5 × 4 cm lesion was present over the left dorsum of forearm with a well established line of demarcation (Fig. 1). The pus culture grew streptococcus pyogenes and the blood culture was sterile. The infant was treated with early debridement, intravenous antibiotics followed by skin grafting on a healthy granulation tissue bed three weeks later. Follow up showed secondary healing.

Fig. 1. Photograph showing two necrotic patches - over left occiput measuring 5×6 cms and a 5 × 4 cm lesion over the left dorsum of forearm.

Necrotizing fascitis is predominantly an adult disorder. It affects diverse parts of the body but involvement of head and neck is uncommon(1). Necrotizing fascitis in neonate is attributable to omphalitis, mammitis, balanitis, postoperative complications and fetal monitoring(2). In children scalp lacerations, cervical adenitis and chicken pox can cause necrotizing fascitis.

The predominant causative bacterii include group B streptococci, group D entero-coccus, group A streptococci, Staphylococcus aureus, Enterobacteriae and anaerobic bacteria(3).

Initial presentation ranges from minimal rash to erythema, edema, induration or cellulitis. These later develop peau d’orange appearance, violaceous discoloration, bullae or necrosis(1,2). Blood cultures in 20% and skin lesions in 30% identify the bacteria(4).

High index of suspicion, prompt aggressive surgery (debridements, release inckisions, excisions, fasciotomy, skin grafting), appropriate antibiotics and supportive care is the mainstay of management, especially in neonates. Survival with only fasciotomy, drainage and antibiotics is reported in few cases(5). Mortality from necrotizing fascitis can be high(1). Survival is related to early diagnosis and adequate treatment.

Paras R. Kothari,
Bharti Kulkarni,
Department of Pediatric Surgery,
L.T.M. Medical College and
General Hospital,
Sion, Mumbai 400 022, India.
E-mail: [email protected]

1. Moss RL, Musemeche CA, Kosloske AM Necrotizing fascitis in children: Prompt recognition and aggressive therapy improves survival. J Pediatr Surg 1996; 31: 1142- 1146.

2. Hsieh WS, Yang PH, Chao HC, Lai JY Neonatal necrotizing fascitis: a report of three cases and review of the literature. Pediatrics 1999; 103: e53.

3. Brook I. Cutaneous and subcutaneous infections in the newborns due to anaerobic bacteria. J Perinal Med 2002; 30: 197-208.

4. Olivier C. Severe streptococcus pyogenes cutaneous infections. Arch Pediatr 2001; Suppl 4: 757s-761s.

5. Chen JW, Broadbent RS, Thomson IA. Staphylococcal neonatal necrotizing fascitis: Survival without radical debridement. NZ Med J 1998; 111: 251-253.