Orbit, 2014; 33(3): 237 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.881647
LETTER TO THE EDITOR
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 04/22/15 For personal use only.
Response to Letter of Pollock, Hassan and Smith, ‘‘Diagnostic Confusion in Periorbital Necrotising Fasciitis’’
Pollock et al. rightly say that ‘‘early involvement of clinicians experienced in the management of complex necrotising skin infections’’ is crucial, and we would agree. Our patient was immediately transferred from our Eye Hospital to the neighbouring General Hospital, where she was co-managed with Plastic Surgeons experienced with this type of infection, as well as infectious disease specialists. She was very carefully monitored throughout her extended stay in hospital. We believe our patient did indeed have necrotising fasciitis, and that she had a good outcome, because the diagnosis was made very early and medical treatment begun immediately, before extensive necrosis had occurred. The review by Hasham et al. points out that the diagnosis is very often delayed and it is this which most likely adversely effects outcome in many patients.2 We would certainly not advocate a conservative approach in more extensive and later presenting cases, and our case report did not suggest this.
We thank Drs. Pollock, Hassan and Smith for their interest in our case report entitled ‘‘Medical Management of Periocular Necrotising Fasciitis,’’ in which we described a patient successfully managed without surgical debridement.1 They believe that we made an incorrect diagnosis, and that the publication of this case might encourage others faced with cases of necrotising fasciitis to manage them without surgery, and place such patients in danger of a worse outcome and an increased risk of death. The reference provided by Pollock et al. on necrotising fasciits has within it a table listing the clinical findings, and dividing them into early and late findings.2 Of the 7 early findings, our patient fulfilled 6, and the seventh, skin anaesthesia, may have been present but was not tested for. Of the 8 late findings, 5 were present, and as the article states, one of these late findings, crepitus, is found in only 37% of cases. Our patient did not, fortunately, develop the 8th finding, multiorgan failure. Our patient also developed full thickness skin necrosis of a relatively small area of the upper and lower eyelids, and the principle organism cultured was a group A beta haemolytic Streptococcus. On this basis, we believe our patient fulfilled the criteria to make a diagnosis of necrotising fasciitis. She was certainly severely ill at presentation, and it was felt that an early diagnosis and treatment allowed us to avoid surgical debridement. We made this point in our report and would have debrided our patient (as we have done in other cases) at a moment’s notice if she had not been continually improving.
Alan A McNab, DMedSc, FRANZCO, FRCOphth Director, Orbital Plastic and Lacrimal Clinic Royal Victorian Eye and Ear Hospital Melbourne, Australia Email: [email protected]
REFERENCES 1. Mehta R, Kumar A, Crock C, McNab A. Medical management of periorbital necrotising fasciitis. Orbit 2013;32: 253–255. 2. Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis. Brit Med J 2005;330:830–833.
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LETTER TO THE EDITOR
Orbit Downloaded from informahealthcare.com by Nyu Medical Center on 04/22/15 For personal use only.
Response to Letter of Pollock, Hassan and Smith, ‘‘Diagnostic Confusion in Periorbital Necrotising Fasciitis’’
Pollock et al. rightly say that ‘‘early involvement of clinicians experienced in the management of complex necrotising skin infections’’ is crucial, and we would agree. Our patient was immediately transferred from our Eye Hospital to the neighbouring General Hospital, where she was co-managed with Plastic Surgeons experienced with this type of infection, as well as infectious disease specialists. She was very carefully monitored throughout her extended stay in hospital. We believe our patient did indeed have necrotising fasciitis, and that she had a good outcome, because the diagnosis was made very early and medical treatment begun immediately, before extensive necrosis had occurred. The review by Hasham et al. points out that the diagnosis is very often delayed and it is this which most likely adversely effects outcome in many patients.2 We would certainly not advocate a conservative approach in more extensive and later presenting cases, and our case report did not suggest this.
We thank Drs. Pollock, Hassan and Smith for their interest in our case report entitled ‘‘Medical Management of Periocular Necrotising Fasciitis,’’ in which we described a patient successfully managed without surgical debridement.1 They believe that we made an incorrect diagnosis, and that the publication of this case might encourage others faced with cases of necrotising fasciitis to manage them without surgery, and place such patients in danger of a worse outcome and an increased risk of death. The reference provided by Pollock et al. on necrotising fasciits has within it a table listing the clinical findings, and dividing them into early and late findings.2 Of the 7 early findings, our patient fulfilled 6, and the seventh, skin anaesthesia, may have been present but was not tested for. Of the 8 late findings, 5 were present, and as the article states, one of these late findings, crepitus, is found in only 37% of cases. Our patient did not, fortunately, develop the 8th finding, multiorgan failure. Our patient also developed full thickness skin necrosis of a relatively small area of the upper and lower eyelids, and the principle organism cultured was a group A beta haemolytic Streptococcus. On this basis, we believe our patient fulfilled the criteria to make a diagnosis of necrotising fasciitis. She was certainly severely ill at presentation, and it was felt that an early diagnosis and treatment allowed us to avoid surgical debridement. We made this point in our report and would have debrided our patient (as we have done in other cases) at a moment’s notice if she had not been continually improving.
Alan A McNab, DMedSc, FRANZCO, FRCOphth Director, Orbital Plastic and Lacrimal Clinic Royal Victorian Eye and Ear Hospital Melbourne, Australia Email: [email protected]
REFERENCES 1. Mehta R, Kumar A, Crock C, McNab A. Medical management of periorbital necrotising fasciitis. Orbit 2013;32: 253–255. 2. Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis. Brit Med J 2005;330:830–833.
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