DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20210458

Fungal necrotizing fasciitis of face- a reconstructive challenge

Deepti Gupta, Sujata Sarabahi, Ananda Murthy K. T., Nupur Aggarwal

Abstract


Fungal necrotizing fasciitis (NF), particularly in the face, is an unusual infection. It is mostly seen in immunocompromised individuals and can be gravely destructive if diagnosis and treatment are delayed. We report this rare case of a 27-year-old, immunocompetent male who presented with gangrenous patch of skin on the cheek following blunt trauma to the right side of the face. Till now no case has been reported in literature with such an extensive soft tissue loss of face and involvement of facial skeleton due to fungal etiology. Clinical suspicion of necrotizing fasciitis led to early surgical intervention. Histopathological examination of the debrided tissue identified the infective organism as Apophysomyces elegans. Intravenous antifungal therapy with liposomal amphotericin B was initiated. Despite the prompt commencement of the treatment, the infection continued to spread, and the patient had to undergo serial debridement which resulted in orbital exenteration, partial maxillectomy and mandibulectomy on the right side. This resulted in a huge soft tissue defect requiring flap cover. A free anterolateral thigh flap was harvested to cover the soft tissue defect, but the blood flow could not be established. For salvage, scalp and pectoralis major muscle flaps were raised and used to cover the large hemifacial defect. The oral lining was created with a folded deltopectoral flap in a second stage. However, there was persistence of the fungal elements in wound bed even after prolonged systemic liposomal amphotericin B therapy and it invaded the flap margins due to which there was partial necrosis of the flap. In this article, we aim to describe the difficulties faced by us in the management of such devastating infection and the reconstructive challenge that it posed.  


Keywords


Necrotizing fasciitis, Fungal infection, Flap cover, Liposomal amphotericin B

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References


Saeed K, Esposito S, Gould I, Ascione T, Bassetti M, Bonnet E,Yalcin AN. Hot topics in necrotising skin and soft tissue infections. Int J Antimicrob Agen. 2018;52(1):1–10.

Shaariyah MM, Marina MB, Mohd Razif MY, Mazita A, Primuharsa Putra SH. Necrotizing fasciitis of the head and neck: surgical outcomes in three cases. Malays J Med Sci. 2010;17(2):51-5.

Meis JF, Chakrabarti A. Changing epidemiology of an emerging infection: Zygomycosis. Clin Microbiol Infect. 2009;15(Suppl 5).

Gomes MZ, Lewis RE, Kontoyiannis DP. Mucormycosis caused by unusual Mucormycetes, non-Rhizopus, -Mucor, and -Lichtheimia species. Clin Microbiol Rev. 2011;24:411-5.

Jain D, Kumar Y, Vasishta RK, Rajesh L, Pattari SK, Chakrabarti A. Zygomycotic necrotizing fasciitis in immunocompetent patients: a series of 18 cases. Mod Pathol. 2006;19:1221-6.

Kumar A, Rattan V, Rai S, Jolly SS, Popat SP, Bhadada SK. Fungal Necrotizing Fasciitis of Craniofacial Region: A Diagnostic Challenge. J Maxillofac Oral Surg. 2020.

Chander J, Stchigel AM, Alastruey-Izquierdo A, Jayant M, Bala K, Rani H, et al. Fungal necrotizingfasciitis, an emerging infectious disease caused by Apophysomyces (Mucorales). Rev Iberoam Micol. 2015;32:93-8.

Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-41.

Vasantha LP, Leela SK. Necrotizing fasciitis due to Apophysomyces elegans. J Acad Clin Microbiol. 2014;16:17-80.

Lakshmi V, Rani TS, Sharma S, Mohan VS, Sundaram C, Rao RR, et al. Zygomycotic necrotizing fasciitis caused by Apophysomyces elegans. J Clin Microbiol. 1993;31:1368-9.

Sipsas NV, Gamaletsou MN, Anastasopoulou A, Kontoyiannis DP. Therapy of mucormycosis. J Fungi (Basel). 2018;4(3):90.

Shindo ML, Nalbone VP, Dougherty WR. Necrotizing fasciitis of the face. Laryngoscope. 1997;107(8):1071-9.