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COMMENTARY
Year : 2016  |  Volume : 7  |  Issue : 4  |  Page : 319-320  

Necrotizing fasciitis associated with systemic lupus erythematosus in a child


Department of Paediatrics, Al-Kindy College of Medicine, Baghdad University, Baghdad, Iraq

Date of Web Publication5-Jul-2016

Correspondence Address:
Mahmood Dhahir Al-Mendalawi
P.O. Box 55302, Baghdad Post Office, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.185496

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How to cite this article:
Al-Mendalawi MD. Necrotizing fasciitis associated with systemic lupus erythematosus in a child. Indian Dermatol Online J 2016;7:319-20

How to cite this URL:
Al-Mendalawi MD. Necrotizing fasciitis associated with systemic lupus erythematosus in a child. Indian Dermatol Online J [serial online] 2016 [cited 2019 Dec 15];7:319-20. Available from: http://www.idoj.in/text.asp?2016/7/4/319/185496

Sir,

I have two comments on the interesting case report by Srinivas et al. on the necrotizing fasciitis (NF) associated with systemic lupus erythematosus (SLE) in an Indian child.[1]

First, the authors nicely addressed the clinical presentation of the patient. The patient was diagnosed with NF based on the positive culture of the tissue and pus revealing Group A Streptococcus, Klebsiella, and Escherichia coli. The patient, unfortunately, ran a rapid deteriorating course and eventually succumbed due to sepsis despite surgical skin debridement and broad-spectrum antibiotic coverage. I presume that the rapid escalation in the clinical picture of the patient necessitates consideration of another concomitant diagnosis. It is obvious that SLE patients are more susceptible to various infections due to impaired immune response. Mucormycosis is well-known to be an invasive fungal infection caused by fungi of the order Mucorales, mainly affecting immunocompromised patients. Cutaneous mucormycosis (CM) is the third most common clinical form of the disease, after pulmonary and rhinocerebral. The agents of mucormycosis are ubiquitous in nature and are transmitted to the skin by direct inoculation, as a result of various types of trauma. These include needle sticks, stings and bites by animals, motor vehicle accidents, natural disasters, and burn injuries. The typical presentation of CM is the necrotic eschar, but it can present with various other signs. The infection can be locally invasive and penetrate into the adjacent fat, muscle, fascia, and bone, or become disseminated.[2] Up to 24% of primary CM can be complicated with NF.[3] In India, the available data pointed out that cases of CM were increasingly reported with an overall mortality of 35%. The most common zygomycete identified was Apophysomyces elegans, and the most common predisposing factor was breach of the skin.[4] It is suggested that a high index of suspicion is needed to diagnose CM. Therefore, it should always be considered among the differentials of necrotic wounds that do not respond to the conventional therapy even in immunocompetent individuals and histopathological study of tissue biopsy and culture in suitable media for fungi should be performed in suspected cases.[3] I presume that if the diagnosis of CM was considered by the authors in the case in question together with the implementation of wound debridement, antibacterial, and antifungal coverage, the rapid clinical deterioration with resultant mortality might be curtailed in the studied patient.

Second, the association between SLE and NF could be addressed in three presentations. (1) The development of NF in SLE patients could occur as a consequence of poor immunity secondary to the disease itself and the immunosuppressive therapy. (2) Patients with NF could be incidentally diagnosed to have occult SLE like the case in question. (3) It is obvious that SLE is a potentially fatal autoimmune disease involving virtually all the key components of the immune system. It is, therefore, suggested that caution should be exercised in the follow-up of NF patients because NF might immediately favor the development of a severe autoimmunity resulting in SLE.[5]

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Srinivas SM, Patil AT, Shankar G, Lakshmikantha KM, Govindraj M. Necrotizing fasciitis associated with systemic lupus erythematosus in a child. Indian Dermatol Online J 2015;6:441-2.  Back to cited text no. 1
  Medknow Journal  
2.
Skiada A, Petrikkos G. Cutaneous mucormycosis. Skinmed 2013;11:155-9.  Back to cited text no. 2
    
3.
Telich-Tarriba JE, Pérez-Ortíz AC, Telich-Vidal J. Necrotizing fasciitis caused by cutaneous mucormycosis. A case report. Cir Cir 2012;80:462-5.  Back to cited text no. 3
    
4.
Kaushik R. Primary cutaneous zygomycosis in India. Indian J Surg 2012;74:468-75.  Back to cited text no. 4
    
5.
Santoro S, Cortelazzi C, Santini M, Santilli D, Pepe CA, Castagnetti S, et al. Systemic lupus erythematosus developing immediately after necrotizing fasciitis. G Ital Dermatol Venereol 2012;147:499-502.  Back to cited text no. 5
    




 

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