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Table of Contents
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 193-196

Necrotising fasciitis following a monkey bite

Department of General Surgery, Dr Mehta Hospital Global Campus, Chennai, Tamil Nadu, India

Date of Submission07-Jul-2021
Date of Decision17-Jul-2021
Date of Acceptance15-Dec-2021
Date of Web Publication08-Jun-2022

Correspondence Address:
Jayabal Pandiaraja
Consultant General Surgeon, 26/1, Kaveri Street, Rajaji nagar, Villivakkam, Chennai 600 049, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcsr.jcsr_42_21

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Necrotising fasciitis (NF) is rapidly spreading bacterial infection of a facial plane. It has a higher mortality rate in patients with diabetes and immunocompromised state. The initial presentation mimics cellulitis and most of the cases are misdiagnosed. Delayed diagnosis and treatment increase mortality by nearly 100%. Our patient had developed NF with septic shock following a monkey bite. The patient underwent prompt fasciotomy along with extensive wound debridement. Later patient underwent secondary suturing with a skin graft for wound cover. NF following money bite is not reported in the literature till now. Hence, early diagnosis and prompt surgical debridement in monkey bites will reduce the incidence of mortality due to NF.

Keywords: Fasciotomy, monkey bite, necrotising fasciitis, septic shock, wound infection

How to cite this article:
Pandiaraja J. Necrotising fasciitis following a monkey bite. J Clin Sci Res 2022;11:193-6

How to cite this URL:
Pandiaraja J. Necrotising fasciitis following a monkey bite. J Clin Sci Res [serial online] 2022 [cited 2022 Aug 12];11:193-6. Available from: https://www.jcsr.co.in/text.asp?2022/11/3/193/347039

  Introduction Top

Necrotising fasciitis (NF) is rapidly spreading bacterial infection of a facial plane. The mortality of NF is around 30% in the general population.[1] It has a higher mortality rate in patients with diabetes and immunocompromised state. It is more common on extremities, but there are reports of NF involving the head-and-neck region and abdomen.

There are three types of NF.[1] Type 1 is polymicrobial (Gram-positive, Gram-negative and anaerobic) which consists of streptococci, staphylococci, enterococci, etc. Type 2 is monomicrobial mainly which consists of Group A streptococci; and type 3 is due to Vibro species or methicilin-resistant Staphylococcus aureus.

  Case Report Top

A 47-year-old male, presented with septic shock along with a swollen right leg. He had sustained a monkey bite on the right leg 1 week ago. The patient presented with a swollen right leg along with foul-smelling discharge from the bite site for the past 5 days [Figure 1]. He had a history of fever with chills and rigors for the past 2 days. He was not known to have diabetes mellitus, hypertension, tuberculosis, ischaemic heart disease or human immunodeficiency virus (HIV) infection. He is not on any immunosuppression drugs. He never consumed alcohol. There was no history of previous surgery.{Figure 1}

On examination, the patient was febrile (temperature 103 oF), blood pressure 90/50 mmHg. pulse 130/min, respirations 31/min. Local examination showed swollen right leg with the erythema. There were three monkey bite marks with foul-smelling discharge. There was local warmth and tenderness. He was resuscitated with inotropic and intravenous fluids.

The blood investigations showed haemoglobin 8 g/dL, total leucocyte count 42,000/mm3, platelets 130,000/mm3, serum urea 44 mg/dL, creatinine 1.4 mg/dL, random blood sugar – 102 mg/dL, glycosylated haemoglobin (HbA1c) 5.5%. Serological testing for HIV-1 and HIV-2, hepatitis B surface antigen (HbsAg) and hepatitis C virus (HCV) was non-reactive.

The patient underwent emergency fasciotomy along with wound debridement under general anaesthesia. Necrotic tissue along with slough was excised extensively [Figure 2]. Pus was taken for culture and sensitivity. The necrosis involved the skin, subcutaneous tissue and fascia. The patient was managed in an intensive care unit under an intensivist following surgery. The patient was started on empirical antibiotics with a calculated dose of cefoperazone with sulbactam and metronidazole. Aminoglycosides were avoided due to increased renal parameters. The patient's condition improved the following debridement and resuscitation. On 6th post-operative day, the patient was shifted to ward. The patient was discharged on day 14 and advised for local dressing. Patient wound improving with good granulation tissue without evidence of wound infection [Figure 3]. The patient underwent wound closure with skin grafting for the raw area [Figure 4]. He is on follow-up for more than 3 years without any complications.{Figure 2}{Figure 3}{Figure 4}

Different types of necrotising fasciitis are listed in [Table 1].{Table 1}

  Discussion Top

NF Type 1 is most commonly associated with diabetes mellitus, prolonged steroid intake, patient on immunosuppression, chronic kidney disease, obesity, malnutrition, HIV infection, intravenous drug abuse, peripheral vascular disease, associated malignancy, gout, congestive heart failure, chronic obstructive pulmonary disease and chronic alcoholic.[2] However, NF 2 can occur even in the young healthy individual without any comorbid conditions. Type 1NF is more common following abdominal and perineal surgery, whereas Type 2 is more common following minor trauma and animal bite (Table 1).

The pathogenic organism gets entry through the skin lesion, insect bite or external injury. After gaining access, the virulent bacteria bind to the muscle using selective cell surface protein. Blunt and penetrating trauma, post-surgical site, following delivery, following burns, following an insect bite, following tattooing and invasive procedure are the provocation factors for NF.

Most early cases of NF mimic cellulitis due to the presence of erythema, oedema, local warmth and tenderness. Only advanced cases show the clinical features of NF. Early diagnosis of NF and prompt treatment save the patient life. There are lots of case reports of NF diagnosed in the late stage and patient life could not be saved.[3]

There are no laboratory parameters that can exactly diagnose NF. Hence, it is always necessary to have a high index of suspicion based on risk factors, history of insect bite or history of animal bite, rapidly progressive systemic sepsis. If clinical features out of proportion of pain, one should consider the differential diagnosis of NF.[4] Early detection and extensive debridement along with fasciotomy are the cornerstones of the management of NF. Because when the debridement is done within 12 h of the onset of symptoms, the mortality rate falls <6%, whereas when the debridement is done after 24 h, the mortality rate is more than 30%.[5]

Broad-spectrum antibiotics should be started as soon as a diagnosis is made. Selective antibiotics can be initiated based on culture and sensitivity reports. Antibiotics alone are not sufficient unless extensive surgical debridement is done.[6] Most of the cases required multiple wound debridement followed by reconstruction using grafting or flap cover. A study[7] showed increased white blood cell count, hyponatraemia, hypoalbuminaemia, anaemia and increased renal parameters were considered poor prognostic factors in a patient with necrotising soft tissue infections.

Our patient is a non-diabetic person who developed NF following a monkey bite. NF following perforated acute appendicitis, which was managed by laparotomy with abdominal wall debridement has been reported.[8] NF following a human bite,[9] dog bite,[2] and caesarean section[10] have been reported

Septic shock, renal failure, coagulation failure, arrhythmia and multi-organs failure are the common causes of mortality in NF. The patient who recovered from NF might have prolonged morbidity due to repeated reconstructive surgery, skin graft or flap and limb loss following amputation.

NF can occur following a monkey bite. Initial presentation of NF mimics cellulitis. Early diagnosis and prompt surgical debridement along with fasciotomy will save the patient life. There are no specific laboratory investigations that diagnostic of NF. Hence, it is always necessary to have a high index of suspicion based on risk factors, history of insect bite or history of animal bite, rapidly progressive systemic sepsis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dapunt U, Klingmann A, Schmidmaier G, Moghaddam A. Necrotising fasciitis. BMJ Case Rep 2013;2013:bcr2013201906.  Back to cited text no. 1
Das DK, Baker MG, Venugopal K. Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: A retrospective chart review. BMC Infect Dis 2012;12:348.  Back to cited text no. 2
Navinan MR, Yudhishdran J, Kandeepan T, Kulatunga A. Necrotizing fasciitis – A diagnostic dilemma: Two case reports. J Med Case Rep 2014;8:229.  Back to cited text no. 3
Vijayakumar A, Pullagura R, Thimmappa D. Necrotizing fasciitis: Diagnostic challenges and current practices. Favory R, Çiftçi E, editors. ISRN Infect Dis 2014;2014:208072.  Back to cited text no. 4
Magala J, Makobore P, Makumbi T, Kaggwa S, Kalanzi E, Galukande M. The clinical presentation and early outcomes of necrotizing fasciitis in a Ugandan Tertiary Hospital – A prospective study. BMC Res Notes 2014;7:476.  Back to cited text no. 5
Schröder A, Gerin A, Firth GB, Hoffmann KS, Grieve A, Oetzmann von Sochaczewski C. A systematic review of necrotizing fasciitis in children from its first description in 1930 to 2018. BMC Infect Dis 2019;19:317.  Back to cited text no. 6
Shah AK, Kumar NB, Gambhir RP, Chaudhry R. Integrated clinical care pathway for managing necrotising soft tissue infections. Indian J Surg 2009;71:254-7.  Back to cited text no. 7
Romanoff A, Freed J, Heimann T. A case report of necrotizing fasciitis of the abdominal wall: A rare, life-threatening complication of a common disease process. Int J Surg Case Rep 2016;28:355-6.  Back to cited text no. 8
Sikora CA, Spielman J, Macdonald K, Tyrrell GJ, Embil JM. Necrotizing fasciitis resulting from human bites: A report of two cases of disease caused by group A streptococcus. Can J Infect Dis Med Microbiol 2005;16:221-4.  Back to cited text no. 9
Makhdoomi MA, Haraga A, Joseph M, Habeeb YA. Necrotising fasciitis of lower anterior abdominal wall post lower segment ceaserian section. Int Surg J 2018;5:3760-3.  Back to cited text no. 10


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