Reconstruction of cervical necrotizing fasciitis defect with the modified keystone flap technique:Two case reports

BACKGROUND Cervical necrotizing fasciitis(CNF)is a rare,aggressive form of deep neck space infection with significant morbidity and mortality rates.Serial surgical debridement acts as the cornerstone of CNF treatment;however,it often results in defects requiring complex reconstructions.CASE SUMMARY We report two cases in which the keystone flap(KF)was used for CNF defect coverage:Case 1,an 85-year-old patient with CNF in the anterior neck,and Case 2,a 54-year-old patient with CNF in the posterior neck.Both patients received empirical intravenous antibiotic therapy and underwent serial debridement,enabling adequate wound preparation and stabilization.The final defect size measured 5.5 cm×12 cm in Case 1 and 6 cm×11 cm in Case 2.For defect coverage,we employed an 8 cm×19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm×18 cm type II KF based on perforators from the transverse cervical artery in Case 2.Both flaps showed complete survival.No postoperative complications occurred in both cases,and favorable outcomes were observed at 7-and 6-month follow-ups in case 1 and 2,respectively.CONCLUSION We effectively treated CNF-associated defects using the KF technique;KF is viable for covering CNF defects in carefully selected cases.

Eosinophilic fasciitis difficult to differentiate from scleroderma:A case report

BACKGROUND Eosinophilic fasciitis(EF)is a rare connective tissue disease that can cause swelling and sclerosis of the extremities,and special attention is needed to differentiate EF from systemic sclerosis.Misdiagnosis or omission markedly delays treatment of EF,and severe skin sclerosis in advanced stages can cause joint contracture and tendon retraction,worsening the patient's prognosis and quality of life.CASE SUMMARY We report a case of EF in a young woman diagnosed by tissue biopsy,confirming the difficulty of differential diagnosis with scleroderma.CONCLUSION Focusing on skin manifestations,completing tissue biopsy and radiography can help diagnose EF effectively.Clinicians should enhance their understanding of the differences between EF and scleroderma,and early diagnosis and standardized treatment can improve the prognosis of patients with EF.

Nodular fasciitis of the external auditory canal: Clinical case report and review of the literature

Nodular fasciitis is a benign reactive soft tissue tumor arising from fibroblasts and myofibroblasts.Its incidence is low and misdiagnosis is frequent especially for malignant lesions.This can lead to inappropriate and unnecessary invasive treatment.Nodular fasciitis of the external auditory canal is extremely rare.So far,around fifteen cases have been reported.We present here the case of a 90-year-old patient with nodular fasciitis of the right external auditory canal.The lesion extends anteriorly for 6.5 cm and reaches the posterior wall of the maxillary sinus.To our knowledge,this is the first case in the literature of an external auditory canal nodular fasciitis presenting as an inflammatory ear polyp with such a wide extension.

Research progress of extracorporeal shock wave therapy for plantar fasciitis

Plantar fasciitis is a common and frequently occurring disease in clinic.It is a kind of local aseptic inflammation caused by chronic strain.In severe cases,pain is unbearable,which affects the quality of life of patients.Extracorporeal shock wave(ESW)is a new non-invasive treatment for bone and muscle diseases.It can significantly relieve the pain and other symptoms of patients with plantar fasciitis,and promote the functional recovery of patients.In order to provide reference for the clinical treatment of plantar fasciitis,this paper reviews the literature of extracorporeal shock wave treatment of plantar fasciitis at home and abroad.

Periocular necrotising fasciitis after traumatic laceration and concurrent COVID-19 infection:a case report

Background:Necrotising fasciitis(NF)is a rare but severe necrotising infection of the subcutaneous tissues.We report a case of periocular NF associated with a concurrent COVID-19 infection and explore potential mechanisms of pathogenesis of COVID-19 infection and necrotising superinfections.Case Description:A 33-year-old previously healthy female presented with right-sided progressive periocular swelling,erythema,pain and fever,two days after sustaining a laceration to the right superolateral brow from a clenched fist.She had a concurrent COVID-19 infection,detected on nasopharyngeal polymerase chain reaction swab thirteen days prior to presentation and again at presentation.She did not have an oxygen requirement.There was a large bulbous collection of the right upper lid with fluctuance and overlying erythema,and a communicating sinus drained frank pus from the superolateral brow.Pre-operative T2-weighted MRI demonstrated fascial hyperintensity involving the pre-septal tissues and extending to the anterior temporal fossa.She was commenced on intravenous meropenem,clindamycin and vancomycin,and underwent early surgical debridement.Initial debridement demonstrated right upper lid necrosis involving the dermal and pre-septal layers,including the orbicularis,but sparing the tarsus.Streptococcus pyogenes was isolated,and she was continued on a prolonged course of intravenous antibiotic.Periocular defects were repaired with a right-sided brow adipo-fascial flap based on the supratrochlear artery,browpexy and dual full thickness skin grafts on the right upper lid and flap.Conclusions:NF is an acute fulminant infection rarely affecting the periocular tissues.This represents a unique case of periocular NF associated with a concurrent COVID-19 infection.

Use of orthotics with orthotic sandals versus the sole use of orthotics for plantar fasciitis:Randomised controlled trial

BACKGROUND Plantar fasciitis(PF)affects around 10%of the population.Prefabricated orthotics with arch support has been shown to provide symptom relief in PF by decreasing the repetitive stress sustained by the plantar fascia.However,prefabricated orthotics are only effective when shoes are worn,meaning the foot may be left unsupported when it is impractical to wear shoes.Using orthotic sandals in conjunction with prefabricated orthotics may increase PF symptom relief,as they can be worn inside the home,extending the period in which the foot is supported.AIM To compare the combined use of prefabricated orthotics and orthotic sandals vs the sole use of prefabricated orthotics in the treatment of PF.METHODS 98 participants with PF were randomised into two groups.The intervention group received the Aetrex L420 Compete orthotics and the Aetrex L3000 Maui Flips(orthotic sandals),whilst the control group received the Aetrex L420 Compete orthotics only.Foot pain was assessed both by the numerical rating scale(NRS)and the pain sub-scale of the foot health status questionnaire(FHSQ).Foot functionality was measured using the function sub-scale of the FHSQ.Symptom change was measured using the global rating of change scale(GROC).RESULTS Foot pain scores measured both by NRS and FHSQ pain sub-scale showed statistically significant reductions in foot pain in both groups(P<0.05)at six months.Both groups also reported statistically significant improvements(P<0.05)in function as measured by the FHSQ function subscale and improvement of symptoms as measured by the GROC scale.Between-group analysis showed that the intervention group with the combined use of orthotics and orthotic sandals scored better on all four outcome measures as compared to the control group with the sole use of orthotics.However,the between-group analysis only reached statistical significance on the NRS pain score(P<0.05).CONCLUSION Combined use of prefabricated orthotics and orthotic sandals provides a greater decrease in foot pain and improvement in foot function in PF compared to using prefabricated orthotics alone.

Necrotizing Fasciitis Secondary to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A Rare Case Report Presentation

Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.

Enteropathica Acrodermatitis Complicated by Necrotising Fasciitis in an Infant Admitted to the Paediatric Emergency Department of the Gabriel Touré University Hospital

Acrodermatitis enteropathica is a rare autosomal recessive genetic disorder characterised by periorificial dermatitis, alopecia and diarrhoea. It is caused by a mutation in the gene that codes for a membrane protein that binds zinc. We report a case in a 7-month-old girl, admitted with altered general condition and scaly, pustular erythematous lesions, initially located in the occipital and cervical regions, and secondarily inguinal and on the knees. Management and outcome in this patient? Genetic assay was not available to confirm this rare genetic disease. A delay in establishing the diagnosis and a disastrous outcome did not save the patient despite the administration of zinc.

Necrotizing fasciitis secondary to enterocutaneous fistula:Three case reports

Necrotizing fasciitis(NF)is an uncommon,rapidly progressive,and potentially fatal infection of the superficial fascia and subcutaneous tissue.NF caused by an enterocutaneous fistula has special clinical characters compared with other types of NF.NF caused by enterocutaneous fistula may have more rapid progress and more severe consequences because of multiple germs infection and corrosion by digestive juices.We treated three cases of NF caused by postoperative enterocutaneous fistula since Jan 2007.We followed empirically the principle of eliminating anaerobic conditions of infection,bypassing or draining digestive juice from the fistula and changing dressings with moist exposed burn therapy impregnated with zinc/silver acetate.These three cases were eventually cured by debridement,antibiotics and wound management.

Psoriatic fasciitis in a pediatric patient: A case report

BACKGROUND Diffuse fasciitis with psoriatic arthritis on magnetic resonance imaging(MRI) has not been previously described in childhood. Here we present the first case report of a pediatric patient developing fasciitis, beyond plantar fasciitis, with psoriatic arthritis.CASE SUMMARY An 11-year-old female was admitted with the complaints of psoriatic rash on the body associated with severe pain in the lower extremities and arthritis in the right knee. Psoriasis was confirmed by skin biopsy, she diagnosed with juvenile psoriatic arthritis. Diagnostic tests did not indicate any pathology except MRI.MRI of the femur and tibia revealed that high-signal inflammatory changes in the subdermal fascia. These findings led to a diagnosis of psoriatic fasciitis.Methotrexate was given for 3 mo but the patient showed no response to therapy;therefore, etanercept was added. However, there was no response to treatment.Etanercept was switched to adalimumab at the sixth month of therapy. Clinical improvement started with therapy of adalimumab within one month. Fasciitis finding in MRI disappeared at seventh months on adalimumab therapy. She has no complaint for two years with adalimumab.CONCLUSION The most effective imaging method is MRI and adalimumab may be the best choice of treatment for psoriatic fasciitis.

Diagnosis and treatment of eosinophilic fasciitis:Report of two cases

BACKGROUND Eosinophilic fasciitis(EF)is a rare disease characterized by inflammation of the fascia with immune system involvement.Failure to promptly diagnose and treat this disease can seriously affect the quality of life of patients.However,no clear and uniform criteria for diagnosis and treatment exist.CASE SUMMARY In this paper,we report two cases of EF,both of which showed symmetrical limb swelling and rigidity,increased eosinophils in the peripheral blood and bone marrow,increased red blood cell sedimentation rate,increased antinuclear antibody titer,and pathological changes in the tissues such as eosinophil and lymphocyte infiltration.Both patients were treated with hormones and cyclosporine,and showed significant improvements in their conditions.CONCLUSION EF is an autoimmune disease causing swelling and sclerosis of the fascia and eosinophilia.It is diagnosable by magnetic resonance imaging,positron emission tomography-computed tomography,blood routine tests,and bone marrow puncture.Glucocorticoids and immunosuppressants are effective treatments.

Occipital nodular fasciitis easily misdiagnosed as neoplastic lesions:A rare case report

BACKGROUND Nodular fasciitis(NF)is a benign disease originating from fascial tissue and most commonly occurs in the extremities,followed by the trunk,head,and neck.NF of the head and neck occurs mainly in the face and neck,and it has not been reported in the occipital region.CASE SUMMARY A 30-year-old man was admitted because of a mass in the left occipital region.Imaging examination revealed a soft tissue nodule in the left occipital area.An enhanced magnetic resonance imaging scan showed characteristic inverted target and fascial tail signs.Histopathological analysis showed a large amount of spindle cell proliferation,and immunohistochemistry showed positive expression of SMA in the spindle cells in the lesion.Finally,nodular fasciitis was diagnosed.CONCLUSION NF of the head and neck is rare,but the possibility of NF should be considered when nodules or masses with rapid subcutaneous growth are found and tenderness in the head and neck is present.Imaging examination,in combination with clinical manifestations and histopathological examination,can improve the diagnostic accuracy for the disease.After diagnosis,local surgical resection is the first choice of treatment.

Necrotizing Fasciitis of the Upper and Lower Limbs: Port Harcourt Experience

Background: Necrotizing fasciitis (NF) is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Aim: To determine the clinical characteristics at presentation, causative pathogens and clinical outcome of NF after aggressive management. Patients and methods: We retrospectively reviewed case notes of patients with NF referred to the Teaching Hospital in Port Harcourt from January 2004 to December 2009. Results: The case notes of over 2,280 patients with history of cellulitis and/or infections of the upper and lower limbs were reviewed. These cases were seen in a five-year period from 2004 to 2009. Seventy five (3.29%) patients had a diagnosis of necrotizing fasciitis and were evaluated. Only those with infections on the lower and upper limbs were further analyzed. Thirty five (46.67%) patients had their infections in the lower limb while 40 (53.33%) patients had their infections in the upper limb. Twenty (26.67%) patients were found to be diabetic on admission. Thirty (30%) patients sustained injuries on their limbs while 5 (6.67%) patients could not give account of their infections. Eleven (14.66%) patients had fixed flexion deformities as their wounds healed and had to have further plastic surgery to extend their limbs and 7 (9.33%) patients died while on admission. Conclusion: Although an early diagnosis of NF can be difficult, a high index of suspicion is required in all patients presenting with unexplained warmth and/or cellulitis of the limbs, so that prompt and aggressive debridement can be carried out with commencement of broad spectrum antibiotics.

The Effects of Pain Neuroscience Education with Conventional Physical Therapy on Chronic Plantar Fasciitis: A Case Study

Background and Purpose: Plantar Fasciitis (PF) is a condition that affects the foot and causes complaints such as pain and stiffness. The most common symptom of this condition is pain. There are many treatment options to deal with this condition, such as conservative therapy, medications, and surgical interventions in rare cases. This case study aims to investigate the potential impact of pain neuroscience education (PNE), combined with a conventional Physical Therapy (PT) program on a 37-year-old-patient with chronic plantar fasciitis. Case description: A 37-year-old male health care professional presented to an outpatient physical therapy clinic with a diagnosis of chronic PF for around two years. The participant had tried several treatment options with no improvement of his symptoms. After undergoing a physical therapy evaluation, he was given a plan of care for twelve sessions by a skilled physical therapist for a six-week period, with each session consisting of 30 minutes of conventional PT, followed by 5 to 15 minutes of PNE. Results: After completing the prescribed plan of care, the patient reported a reduction in subjective symptoms via the Visual Analog Scale (VAS). He also reported improvement with symptoms and functional independence via the Foot Function Index (FFI). The patient reported no change in the quality of sleep via Pittsburg Sleep Quality Index (PSQI). Lastly, he demonstrated no objective improvement in foot pressure with the Navicular Drop Test. Discussion: This case report indicates that PNE, combined with conventional PT for PF can have a positive impact on subjective pain and foot function. PNE should involve many topics about the physiology of pain and the nervous system and should be administered by a certified therapeutic pain specialist. Further studies are recommended to investigate the impact of this intervention in combination with traditional PT for PF in larger populations.

Multidisciplinary treatment of a patient with necrotizing fasciitis caused by Staphylococcus aureus: A case report

BACKGROUND Necrotizing fasciitis is a severe bacterial skin infection that spreads quickly and is characterized by extensive necrosis of the deep and superficial fascia resulting in the devascularization and necrosis of associated tissues.Because of high morbidity and mortality,accurate diagnosis and early treatment with adequate antibiotics and surgical intervention are vital.And timely identification and treatment of complications are necessary to improve survival of patient.CASE SUMMARY We report a case of necrotizing fasciitis caused by Staphylococcus aureus in a patient using high doses of glucocorticoid and suffering from secondary diabetes mellitus.He was admitted to our hospital due to redness and oedema of the lower limbs.After admission,necrotizing fasciitis caused by Staphylococcus aureus was considered,and he was discharged after B-ultrasound drainage and multiple surgical operations.In the process of treatment,multiple organ functions were damaged,but with the help of multi-disciplinary treatment,the patient got better finally.CONCLUSION The key to successful management of necrotizing fasciitis is an early and accurate diagnosis.The method of using vacuum sealing drainage in postoperative patients can keep the wound dry and clean,reduce infection rate,and promote wound healing.Interdisciplinary collaboration is a vital prerequisite for successful treatment.

Necrotizing fasciitis of lower extremity due to diverticulitis perforation:a case report

Rationale: Necrotizing fasciitis is an aggressive infection of subcutaneous tissues, which tends to spread rapidly through the fascial planes. Colonic diverticulosis is a common disease in advanced age, although it rarely causes a lethal necrotizing soft-tissue infection. Patient concerns: A 58-year-old woman complained of left leg pain for 15 d without abdominal pain. Diagnosis: Diverticulitis perforation presented as necrotizing fasciitis of the left thigh. Interventions: Extensive debridement. Outcomes: The patient died due to sepsis-induced multiple organ failure and severe metabolic acidosis. Lessons: Clinicians should be aware of presentations of diverticulitis in patients who have a soft-tissue infection in lower extremity even though patients may not have had a history of diverticulosis or abdominal pain.

Necrotizing fasciitis following mild trauma in a patient with mellitus diabetes: a case report

Rationale: Necrotizing fasciitis is a rare infection of fascia tissues. It progresses quickly and has high morbidity and mortality. In this study, we aimed to explore a case of necrotizing fasciitis in a diabetic patient. Patient concerns: A 46-year-old woman presented with severe pain and inflammation in the left leg, and with fever and chills. Diagnosis: Necrotizing fasciitis in the left leg. Intervention: Broad debridement of infectious tissues and broad-spectrum venous antibiotics. Outcomes: The patient was discharged without pain, inflation, or fever. Lesson: This disease is a surgical emergency, therefore, early diagnosis and quick and invasive treatment could significantly decrease morbidity and mortality.

Intravascular fasciitis involving the external jugular vein and subclavian vein:A case report

BACKGROUND Intravascular fasciitis(IVF)is a rare nodular fasciitis that often involves the layers and lumens of blood vessels;therefore,it is easily misdiagnosed as a malignant tumor with invasion into blood vessels.CASE SUMMARY A 13-year-old boy was admitted due to a mass on the left side of his neck.Duplex ultrasonography revealed a circular solid hypoechoic mass in the external jugular vein,and magnetic resonance imaging revealed an enhanced longitudinal masslike lesion in the left supraclavicular fossa.Surgical treatment was arranged and completed,histopathological analysis showed a large amount of spindle cell proliferation,and immunohistochemistry showed that the spindle cells were positive for the expression of vimentin,caldesmon,and smooth muscle actin and negative for the expression of S-100 protein,desmin,CD34,and c-kit;Ki-67 staining revealed a low proliferative index(5%-10%),which confirmed the differentiation characteristics of myofibroblasts.Fluorescence in situ hybridization detected the rearrangement of USP6.IVF was subsequently diagnosed.CONCLUSION IVF is characterized by intraluminal,intramural and extramural involvement of small to large arteries or veins.Unless the doctor has a deep understanding of the disease or suspects that there is an initial indicator,IVF may be confused with other intravascular malignancies,leading to unnecessary radical surgery.Imaging examination combined with histopathological examination can improve the diagnostic accuracy of this disease.

Giant nodular fasciitis originating from the humeral periosteum:A case report

BACKGROUND Nodular fasciitis(NF)is a self-limiting tumor that mostly occurs in the subcutaneous superficial fascia.NF originating from the appendicular periosteum is extremely rare.A large NF lesion of periosteal origin can be misdiagnosed as a malignant bone tumor and may cause overtreatment.CASE SUMMARY A right axillary mass was found in a 46-year-old man and was initially diagnosed intraoperatively as low-grade sarcoma,but later diagnosed as NF after postresection histopathological evaluation.Furthermore,fluorescence in situ hybridization analysis revealed a USP6 gene rearrangement that confirmed the diagnosis.To the best of our knowledge,this is the first case of NF in the humeral periosteum.CONCLUSION NF poses a diagnostic challenge as it is often mistaken for sarcoma.Postoperative histopathological examination of whole sections can be combined with immunohistochemical staining and,if necessary,the diagnosis can be confirmed by molecular detection,and thus help avoid overtreatment.

Secondary craniofacial necrotizing fasciitis from a distant septic emboli: A case report

BACKGROUND Craniofacial necrotizing fasciitis(CNF)is an uncommon but fatal infection that can spread rapidly through the subfascial planes in the head and neck region.Symptoms usually progress rapidly,and early management is necessary to optimize outcomes.CASE SUMMARY A 43-year-old man visited our hospital with left hemifacial swelling involving the buccal and submandibular areas.The patient had fever for approximately 10 d before visiting the hospital,but did not report any other systemic symptoms.Computed tomography scan demonstrated an abscess with gas formation.After surgical drainage of the facial abscess,the patient’s systemic condition worsened and progressed to septic shock.Further examination revealed pulmonary and renal abscesses.Renal percutaneous catheter drainage was performed at the renal abscess site,which caused improvement of symptoms.The patient showed no evidence of systemic complications during the 4-mo post-operative follow-up period.CONCLUSION As the patient did not improve with conventional CNF treatment and symptoms only resolved after controlling the infection,the final diagnosis was secondary CNF with septic emboli.Aggressive surgical decompression is important for CNF management.However,if symptoms worsen despite early diagnosis and management,such as pus drainage and surgical intervention,clinicians should consider the possibility of a secondary abscess from internal organs.