Periorbital necrotising fasciitis after minor trauma

Necrotising fasciitis or streptococcal gangrene is a rare and often fatal soft tissue infection usually affecting the limbs and trunk. Facial involvement is exceedingly rare due to the excellent blood supply of this region.

We report a case of initially misdiagnosed streptococcal gangrene of the eyelids precipitated by minor trauma and which progressed despite intensive medical therapy.

A 53-year-old man with a history of alcohol abuse developed rapidly increasing left-sided periorbital oedema, erythema and skin vesicles soon after sustaining a laceration to his left upper lid. It was initially treated as herpes zoster ophthalmicus complicated by a secondary bacterial cellulitis. Bacterial cultures grew group A beta haemolytic Streptococcus pyogenes. Despite 8 days of high-dose parenteral antibiotic therapy and oral acyclovir, characteristic blisters formed and necrosis of the periorbital skin and subcutaneous tissues ensued. Surgical debridement was performed and the fasciitis rapidly resolved.

Physicians and ophthalmologists must be aware of the risk factors, although rare, for periorbital necrotising fasciitis and the cardinal signs that differentiate this condition from common non-necrotising preseptal cellulitis. Prompt recognition and early surgical debridement are crucial in limiting the morbidity and mortality from severe forms of this disease.