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Surgical implications of necrotizing fasciitis in children with chickenpox
J H Waldhausen1, M J Holterman, R S Sawin
1Division of Pediatric Surgery, Children's Hospital and Medical Center, Seattle, WA 98105, USA.
Insights
Children with chickenpox (varicella) developing severe symptoms like fever, rapid heart rate, and high band counts may have necrotizing soft tissue infections. Prompt surgical intervention is recommended for these serious cases to ensure good outcomes.
Area of Science:
- Pediatric Infectious Diseases
- Surgical Infections
- Dermatology
Background:
- Varicella (chickenpox) affects many children annually.
- Complications include severe necrotizing soft tissue infections (NSTIs) from bacteria like Group A Streptococcus.
- Early diagnosis and surgical intervention are critical but often delayed.
Purpose of the Study:
- To identify clinical indicators differentiating children with varicella who require surgery for NSTIs from those who do not.
- To evaluate the effectiveness of early surgical intervention in managing varicella-associated NSTIs.
Main Methods:
- Retrospective review of 30 pediatric patients with varicella and clinical concern for NSTI (December 1993 - June 1995).
- Analysis of clinical parameters: tachycardia, band count, temperature, and lesion characteristics.
- Comparison of surgical versus non-surgical management outcomes.
Main Results:
- 22 of 30 patients required surgery (18 for necrotizing fasciitis, 4 for abscesses).
- Surgical patients commonly presented with fever (>4 days post-onset), tachycardia, and elevated band counts (>5%).
- Severe pain, erythema, and induration were key symptoms in surgical cases. 100% survival rate observed.
Conclusions:
- Children with varicella presenting >2-3 days post-onset with fever, tachycardia, and an elevated band count, plus an erythematous, indurated, painful lesion, should be presumed to have necrotizing fasciitis.
- Immediate surgical exploration is recommended for suspected NSTIs to avoid significant morbidity and mortality.
- Prompt surgical and medical management leads to favorable outcomes.
Abstract:
Varicella (chickenpox) affects approximately 90,000 children each year. Although most cases resolve, some develop necrotizing soft tissue infections secondary to group A streptococcus and staphylococcus. Delay in diagnosis is common. At the time of initial presentation, the need for surgical intervention is not always clear. The authors conducted a retrospective review of 30 patients with varicella (seen from December 1993 to June 1995) for whom there was clinical concern for necrotizing soft tissue infection. Various parameters were examined, including tachycardia, band count, temperature, and clinical symptoms, to differentiate the children who required surgery from those who did not. Of the 30, 22 underwent surgery. Eighteen had necrotizing fasciitis and required debridement, and four had abscesses that were incised and drained. Eight patients had simple cellulitis and did not require operation. Group A streptococcus was the most common organism cultured. All patients were treated with appropriate antibiotics. Twenty of the 22 surgical patients had elevated band count (> or = 5%), 21 had tachycardia, and 18 were febrile at the time of presentation (> 4 days after the onset of chickenpox). Although all patients with necrotizing fasciitis had tachycardia, this sign was a less specific indicator for surgery than was increased band count. Severe pain, erythemia, and induration was the most common signs/symptoms in the surgical patients. The survival rate for these 30 patients was 100%, and there was little long-term morbidity. The authors recommend immediate surgical intervention for children with chickenpox who present more than 2 or 3 days after the onset of the viral illness with symptoms that include fever, tachycardia, and an elevated band count in association with an erythematous, indurated, painful lesion. With this sign/symptom complex, the presumptive diagnosis must be necrotizing fasciitis until proven otherwise. If the patient has suspicious symptoms or if these symptoms are associated with tachycardia or an elevated band count, the patient warrants admission, institution of intravenous fluids, nafcillin, clindamycin, and close observation over several hours. If the symptoms progress over the next few hours or if the tachycardia persists despite rehydration and antibiotics, the patient should be taken to the operating room for exploration. The authors strongly endorse such exploration despite the risk of a negative operation, because the morbidity and mortality associated with delayed surgical treatment are potentially significant. With prompt aggressive surgical and medical treatment, a good outcome can be anticipated for these patients.