chondroitin-sulfates and Meningococcal-Infections

Necrotizing fasciitis (NF) and purpura fulminans (PF) are conditions with extensive septic skin necroses that are associated with significant morbidity and mortality. NF is caused by fulminant bacterial spread on the superficial muscle fascia, Group A streptococcus being the main microorganism responsible for it. The major challenge NF poses is timely recognition. Although crucial for patient survival, early diagnosis is difficult because paucity of specific early findings does not allow setting NF apart from other, less severe, differential diagnoses. Surgical therapy consists of early and aggressive debridement of all affected tissue, even if large disfiguring wounds are left back. The responsible microorganism for PF in children is predominantly Neisseira meningitidis. Endotoxin triggered misbalance of anticoagulant and procoagulant activities of endothelial cells leads to disseminated intravascular coagulation (DIC) followed by microvascular thrombosis and bleeding, resulting in hemorrhagic skin infarction and limb ischemia. Although survival in PF is not dependent on surgery, and surgery plays not a key role in the early phase of the disease, early surgical consult to assess if limb perfusion can be improved to achieve limb salvage is still absolutely necessary. Debridement should be postponed until clear demarcation has established. Large defects after NF and PF can be successfully reconstructed with vacuum-assisted fixation of Integra (Integra LifeSciences Corporation, Plainsboro, New Jersey, United States) artificial skin before split-thickness skin grafting. This provides good functional and cosmetic results as well as good stump coverage in case of amputation in PF.

Topics: Amputation, Surgical; Child; Chondroitin Sulfates; Collagen; Debridement; Fasciitis, Necrotizing; Humans; Limb Salvage; Meningococcal Infections; Negative-Pressure Wound Therapy; Neisseria meningitidis; Plastic Surgery Procedures; Purpura Fulminans; Skin Transplantation; Skin, Artificial; Streptococcal Infections; Streptococcus pyogenes; Treatment Outcome

Meningococcal sepsis leading to purpura fulminans leaves survivors with extensive areas of skin and soft-tissue necrosis. Soft-tissue loss in the limbs may result in large areas of exposed bone, leaving a choice between free tissue transfer and amputation. We present a case of meningococcal sepsis where the entire medial and lateral surfaces of the tibiae were exposed with loss of anterior muscle compartments on each side. Faced with the possibility of bilateral above-knee amputation, these were instead covered using the dermal replacement Integra (Integra LifeSciences Corp.), in conjunction with an antimicrobial dressing, topical negative pressure dressing and subsequent skin grafting. This management decision achieved rapid wound closure avoiding amputation. Additional secondary reconstruction with microvascular free flaps was performed to preserve joint function.

Topics: Adult; Bacteremia; Chondroitin Sulfates; Collagen; Female; Humans; IgA Vasculitis; Limb Salvage; Meningococcal Infections; Necrosis; Plastic Surgery Procedures; Skin