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PHOTO ESSAY
Year : 2019  |  Volume : 67  |  Issue : 10  |  Page : 1721-1722

Periorbital necrotizing fasciitis due to Klebsiella pneumoniae in an immunocompetent patient


1 Department of Ophthalmology, Kalpana Chawla Government Medical College, Karnal, India
2 Department of Surgery, Kalpana Chawla Government Medical College, Karnal, India
3 Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission22-Feb-2019
Date of Acceptance26-Apr-2019
Date of Web Publication23-Sep-2019

Correspondence Address:
Dr. Sumeet Khanduja
Department of Ophthalmology, Kalpana Chawla Government Medical College and Hospital, Karnal - 132 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_360_19

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  Abstract 


Keywords: Klebsiella pneumonie, periorbital necrotizing fasciitis, pre-septal cellulitis of the eyelid


How to cite this article:
Sud R, Sharma P, Garg G, Takkar B, Khanduja S. Periorbital necrotizing fasciitis due to Klebsiella pneumoniae in an immunocompetent patient. Indian J Ophthalmol 2019;67:1721-2

How to cite this URL:
Sud R, Sharma P, Garg G, Takkar B, Khanduja S. Periorbital necrotizing fasciitis due to Klebsiella pneumoniae in an immunocompetent patient. Indian J Ophthalmol [serial online] 2019 [cited 2019 Oct 21];67:1721-2. Available from: http://www.ijo.in/text.asp?2019/67/10/1721/267441



A 52-year-old female presented with complaints of bilateral painful lid swelling since 2 days. On examination, there was bilateral lid edema with periocular skin necrosis and eschar formation [Figure 1]a. The necrotic skin had a wooden consistency (like a thick tree bark) and was insensitive to tactile and painful stimuli. A clinical diagnosis of periorbital necrotizing fasciitis (PNF) was made and immediate surgical debridement was performed. During surgery, debridement was done till plane of vital tissue (identified as petechial hemorrhages and till nociceptive stimuli elicited a positive response) was reached [Figure 1]b. Evaluation of the debrided tissue and the purulent discharge showed the presence of Gram-negative bacilli, and parenteral amikacin was administered. Subsequently, microbial cultures grew Kleibsella pnuemoniae sensitive to amikacin. Complete blood counts were normal and serology was negative for HIV. Daily wound care with slough removal from wound base, excision of new necrotic skin at the margins, and wound dressing with gauze soaked in povidone iodine and amikacin was done. Parenteral amikacin was continued for two weeks till no pus could be exuded from the ulcer margin following tactile pressure, and till the ulcer base stopped sloughing. Subsequently, healthy granulation tissue was observed at 1 month [Figure 1]c, and spontaneous scar formation with resolution of the cutaneous defect by 2 months aided by conservative local therapy [Figure 1]d.
Figure 1: (a) Periorbital necrotizing fasciitis at presentation (b) Immediate post debridement with vital tissue in the wound bed (c) Healthy pink granulation tissue can be seen at the bed of the healing ulcer (d) Complete resolution of skin defect and scar formation

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PNF usually occurs after trauma (75% have a positive history), especially in immunocompromised patients. It carries a high risk of mortality.[1],[2] Streptococcus is the most common single organism responsible, followed by Pseudomonas. To our knowledge, this is the first report of PNF due to Kleibsella pnuemoniae. PNF has few peculiar features and different behavior from necrotizing fasciitis elsewhere in the body. The blood rich orbicularis acts as a barrier to the spread of infection to the orbit. Since the dermis is attached to the nasojugal fold medially and malar fold laterally there is some resistance to the spread of infection to the cervicofacial region. However, if these barriers are breached, the infection spreads rapidly to the thoracic skin leading to further complications such as septicemia, toxic shock, and multiorgan failure. Tissue healing in PNF is accompanied by cicatrisation which may lead to ectropion and exposure keratopathy, and require lid surgeries for rehabilitation.[2]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chauhan D, Arora R, Das S, Shroff D, Narula R. Bilateral periorbital necrotizing fasciitis following exposure to Holi colors: A case report. Indian J Ophthalmol 2007;55:373-4.  Back to cited text no. 1
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2.
Amrith S, Hosdurga Pai V, Ling WW. Periorbital necrotizing fasciitis - a review. Acta Ophthalmol 2013;91:596-603.  Back to cited text no. 2
    


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