A presentation of facial necrotizing fasciitis with orbital involvement
A 49-year-old woman fell whilst bathing and struck her face on the bath tap faucet. She sustained a 5 cm partial thickness laceration below her left eye, arising adjacent to the medial canthus and extending to the left malar prominence. The patient promptly attended her local Accident & Emergency (A&E) department and the laceration was debrided, irrigated and sutured. Medical history included Elhers–Danlos syndrome, ischaemic heart disease and previous anaphylaxis to penicillin.\nThe following day she returned to A&E complaining of pain and swelling below the left eye. The eye was partially closed secondary to lower lid swelling, and eye examination was normal with no deficit in visual acuity recorded. The patient was systemically well and discharged with oral clarithromycin in view of penicillin allergy for a possible wound infection.\nThe following day she re-attended A&E and found to be pyrexial (38.7°), tachycardic (102/min) with evidence of rigors and confusion. Extensive left-sided facial swelling, with complete closure of the left eye and involvement of the soft tissues of the left neck, was noted. A reduction in left visual acuity was noted. Urgent blood results identified a marked neutrophilia and raised C-reactive protein consistent with acute bacterial infection. The laceration was opened, necrotic skin edges and an absence of bleeding was recognized and severe facial necrotizing fasciitis considered a likely diagnosis.\nThe woman was admitted and underwent immediate widespread local excision of necrotic tissue extending from and including the left lower eyelid, left cheek and the soft tissues overlying the left angle of mandible and lateral aspect of upper neck (Fig. ). Peri-operative and post-operative intravenous (IV) clindamycin and gentamicin was administered as per local protocol for severe skin sepsis and the patient was transferred to the intensive care unit (ICU) for post-operative support.\nOn review the following morning, the patient remained clinically septic with clear extension of necrotic tissue outwith existing surgical margins. Left eye involvement was suspected and an urgent computerized tomography (CT) scan identified tissue features in keeping with a left retro-orbital necrosis secondary to a rapidly spreading facial necrotizing fasciitis. After close liaison with several senior colleagues, the patient underwent further surgical excision of necrotic tissue affecting the left forehead, left temporal region, left upper eyelid and left commissure with concomitant exenteration of left orbital contents (Fig. ).\nBlood and tissue samples sent to the microbiology laboratory, all of which cultured a florid growth of a Group A beta-haemolytic Streptococci, confirmed the clinical suspicion of facial necrotizing fasciitis.