Orbit, 2014; 33(3): 236 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.881401


Diagnostic Confusion in Periorbital Necrotising Soft Tissue Infections Jonathan Pollock1, Abdul Rahman Hassan2, and Matt Smith1

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Department of Plastic and Reconstructive Surgery, Leicester Royal Infirmary, Leicester, UK and 2 University of Leicester Medical School, Leicester, UK

We read the article by Mehta et al.1 with great interest as we were intrigued to hear about a new approach to the management of necrotising fasciitis. However, upon reading it is clear that the authors have made an incorrect diagnosis, which makes the conclusions of their article invalid and may encourage others to pursue a potentially dangerous treatment course. The patient described in the case report has group A Streptococcal toxic shock syndrome, which is very commonly associated with hypotensive episodes, renal failure and necrotic skin,2 and is well known to be treated with antibiotics and systemic support rather than surgery. This falls under the category of necrotising soft tissue infections but, unlike necrotising fasciitis, is limited to the skin. In contrast, necrotising fasciitis causes full thickness tissue death extending down to the fascia, and has little or no response to antibiotic treatment. Whilst the diagnosis is initially a clinical one, confirmation of full thickness tissue necrosis, and turbid ‘‘dishwater’’ fluid in the fascial plane must be made operatively to confirm necrotising fasciitis.3 This fundamental confusion between necrotising fasciitis and other more superficial necrotising soft tissue infections may encourage clinicians unfamiliar

with true necrotising fasciitis to trial medical management, which could result in a fatal delay in surgical intervention. Early involvement of clinicians experienced in the management of complex necrotising soft tissue infections is critical, and prompt surgical exploration remains the gold standard for suspected necrotising fasciitis.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES 1. Mehta R, Kumar A, Crock C, McNab A. Medical management of periorbital necrotising fasciitis. Orbit 2013; 32(4):253–255. 2. Hung JAZ, Rajeev P. Streptococcal toxic shock syndrome following total thyroidectomy. Ann R Coll Surg Engl 2013; 95:457–460. 3. Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis. Br Med J 2005;330:830–833.

Received 4 October 2013; Accepted 6 January 2014; Published online 20 February 2014 Correspondence: Mr Jonathan Pollock, Specialty Registrar Plastic Surgery, Leicester Royal Infirmary, 34 Hollies Drive, Edwalton, Nottingham, NG12 4BZ, UK, E-mail: [email protected]


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