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An 87-year-old female was found at home by her family and appeared confused with significant right-sided facial swelling and erythema six days prior to presentation. Upon arrival to UIHC, initial ophthalmologic evaluation revealed no light perception vision in the patient's right eye. Figure 2: The patient's cat succumbed to an infection which began in the right eye and eventually led to necrosis of the right face. Review of Systems: Negative except for what is detailed in the history of present illness. OD: The superior lid appeared to be friable with frank pus weeping through the eyelid, violaceous erythema, and moderate edema of the periorbital region. The clinical picture did not fit with an exclusive orbital cellulitis or orbital compartment syndrome for several reasons.
The patient was started on IV vancomycin and piperacillin-tazobactam, with the addition of clindamycin for its antitoxin effects. Figure 4: An incision was made along the inferior orbital rim and superior retraction with a 4-0 silk suture shows clearly necrotic tissue involving the right lower eyelid. Figure 6: Several days post-operatively after changing her wound vacuum, which was used to help speed granulation of her orbital tissue. Necrotizing soft tissue infections, including cellulitis, myositis, and fasciitis, are devastating infections characterized by fulminant tissue necrosis. An epidemiologic study which gathered data from 2000-2004 identified 3.5 cases of invasive group A Streptococcus (GAS) infection per 100,000 persons in the United States, which included cases of sepsis, bacteremic pneumonia, necrotizing fasciitis, and streptococcal toxic shock syndrome (3).
Necrotizing soft tissue infections are divided into two separate entities: type I (polymicrobial infection) and type II (GAS infection).
Causative factors for periorbital necrotizing fasciitis are able to be identified in 70% of cases, with penetrating or surgical trauma accounting for the majority (48%) of cases (9). Advanced integument involvement, including bullous lesions, skin necrosis or large ecchymoses (1). The differential diagnosis for a patient with this clinical presentation includes necrotizing fasciitis, anaerobic cellulitis, erysipelas, anaerobic myositis, pyomyositis, phycomycosis, and warfarin-induced skin necrosis (12). Ultimately, surgical exploration and culture is the only way to definitively diagnose a necrotizing infection. Surgical exploration and debridement, broad spectrum antibiotics, and hemodynamic support are the mainstay of therapy. Hyperbaric oxygen and intravenous immunoglobulin (IVIG) have been proposed as adjunctive treatments for necrotizing infections.
Group A Streptococcus is an incredibly virulent organism, and cases of nosocomial transmission of necrotizing fasciitis have been reported (19). Necrotizing fasciitis is associated with high morbidity and mortality, though aggressive surgical treatment has helped improve outcomes over the past 100 years.
Answer: Complete ophthalmic examination, including cranial nerve testing, color vision testing and ocular motility testing. Being a little under the weather this week prompted me to make my own cold-busting, immune boosting tisane…AKA homemade NeoCitran without the pharmaceuticals and unpronounceable additives. This recipe features all the big immune boosting herbals, including ginger, garlic and turmeric.  I also opted to use one of my new favorite herbal teas from Blue Hour Tea – handcrafted locally in Edmonton!  Their Sleep Blend tea is a recent addition to my evening wind-down ritual and contains a soothing blend of lemon grass, spearmint, chamomile and flower petals.
This is a concentrated mixture that needs to be diluted prior to serving.  To prepare the tisane, mix one part hot water with one part concentrate.  Add more honey if desired, garnish with lemon slices and enjoy! The Golden Era Arms workout from MusclePharm can be throwin into your training program if you want to get bigger biceps. The Adobe Flash Player is required for video playback.Get the latest Flash Player or Watch this video on YouTube.
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Her WBC count on admission was 21,900 per mm3 despite IV antibiotic therapy with vancomycin and ampicillin-sulbactam.
Although the patient presented with ophthalmoplegia and vision loss, the vision loss was quite dramatic and there was lack of impressive periorbital edema.
She was taken emergently to the operating room where a tissue biopsy revealed necrotizing fasciitis. Necrotizing fasciitis tracks along the superficial fascia as well as overlying subcutaneous fat; muscular fascia is less commonly involved (1). The number of invasive GAS infections in the United States was projected to be 8,950-11,500 cases per year, resulting in 1,050-1,800 deaths per year (3). Type I infections involve at least one anaerobe, plus one or more facultative anaerobic streptococci (other than GAS) or Enterobacteriaceae (5, 6). Necrotizing fasciitis has been described in previously healthy patients with no known trigger for infection. Initially, patients often have pain out of proportion to physical exam findings, which is a clinical clue to the diagnosis of necrotizing fasciitis (10). Aggressive surgical debridement within 24 hours of patient presentation is associated with better patient outcomes; mortality rates increase as the time from admission to operation expands (6).
A cohort study performed in 2014 compared 117 cases treated with hyperbaric oxygen treatment (HBOT) to over 1,400 controls that did not receive HBOT (15). Periorbital necrotizing fasciitis is associated with a reported treated mortality rate of 8-15% (4, 20) and rate of vision loss of 13-30% (4, 20).
Although it can be clinically elusive, it is important to have a low threshold for diagnosis, because early and aggressive surgical intervention is associated with better outcomes. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004.
Group A streptococcal bacteremia: the role of tumor necrosis factor in shock and organ failure. Improved results from a standardized approach in treating patients with necrotizing fasciitis.
The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.
Not just full of hot air: hyperbaric oxygen therapy increases survival in cases of necrotizing soft tissue infections. Effectiveness of clindamycin and intravenous immunoglobulin, and risk of disease in contacts, in invasive group a streptococcal infections. 54 year old man with 4 days of progressively worsening pain and swelling around the right eye. Along with NingXia Red’s premium flavor, these essential oils also aid in maintaining the body’s normal cellular function. The natural flavor is further enhanced by zero-calorie stevia (Rebaudioside A), essential oils, plus blueberry, cherry, and aronia juice. In fact, recent studies indicate that drinks containing wolfberry exhibit longer-lasting supportive effects on energy and caloric metabolism. NingXia Red also contains zeaxanthin, a carotenoid suggested to enhance healthy visual function. The 750-ml bottles are available in two, four, six, and eight packs, allowing you to enjoy even more of this power-packed beverage. NingXia Red 2-ounce, single-serve sachets are a perfect, portable way to take the natural goodness of whole wolfberries and pure essential oils with you wherever you go. The NingXia Red combo pack includes two 750-ml bottles and one 30-count box of single serve sachets of this healthy, nutrient-rich, and essential oil-infused superfruit beverage.
These tart, tasty berries are an excellent, healthy addition to your favorite cereals, yogurt, salad, trail mix, and baked goods. Her table was elegantly dressed and each setting had warm towels, bowls and gold spoons for sampling the Young Living beauty products.
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The patient was admitted to an outside hospital and a maxillo-facial CT revealed pre-septal soft tissue enhancement. The patient's family reported that she had no history of facial trauma, sinus disease, or recent surgery. There is crusting of ocular discharge and necrosis of the superficial tissue of the lower eyelid skin. The eyelids were not tense as would be expected in compartment syndrome, but instead were soft.
She then underwent exenteration of the right orbit and radical debridement of right facial soft tissues (Figures 4 and 5). When narrowing to only periorbital necrotizing fasciitis infections, a study done in the UK found an incidence of 0.24 cases per 1,000,000 persons (4).
Other known risk factors include chemotherapy, immunosuppression, and the presence of other infections (9).

The infection progresses rapidly from cutaneous erythema to skin breakdown with bullae, containing violaceous fluid, to frank cutaneous gangrene. The patient often must return to the OR within 24-36 hours for further debridement after the initial operation (1). However, it is reasonable to consider post-exposure prophylaxis in a close contact of an affected individual who is highly susceptible to infection, such as immunocompromised persons or persons who have had recent surgery. Modern therapeutics have reduced the morbidity and mortality so that many patients recover with few sequelae. NingXia Red, has been cherished for centuries for its health, energy, and longevity benefits.
It would start with allergies, turn into a sinus infection and then transition into bronchitis that would last for months. In fact, when compared to other similar superfruit beverages in a major university study, the new NingXia Red was preferred by 77% of participants over all other options in a blind taste panel! NingXia Red is an easy way to get pure, premium Ningxia wolfberries and experience natural, sustained support for energy without the crashes and harmful side effects of coffee or energy drinks.
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She was started on intravenous (IV) vancomycin and ampicillin-sulbactam treatment for orbital cellulitis.
One family member did report that a possible source of infection was the patient's cat who had died two weeks prior from a suspected eye infection that eventually "eroded through the jaw bone," which they believed was the cause of its death (Figure 2). Antibiotic regimens should include coverage for gram-positive, gram-negative, and anaerobic organisms including Clostridium and group A Streptococcus. Survival rate with operation at 24 hours from time of admission was 93%, declining to 75% with operation at 48 hours from time of admission (6). Whole Ningxia wolfberries combined with other nutrient-dense fruit juices make NingXia Red the perfect choice for optimizing wellness and stepping up to a whole new level of health.
The family member reported that the patient was very close to her cat and slept with it often, even throughout its illness. Finally, her clinical course quickly and dramatically worsened after initial improvement on broad spectrum IV antibiotics. A peripherally inserted central catheter (PICC) line was placed and the patient received IV piperacillin-tazobactam for three weeks. Development of anesthesia is another important clinical clue that points to the diagnosis of necrotizing fasciitis, particularly helping distinguish fasciitis from myositis (11).
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Given these factors, there was a high level of suspicion for necrotizing fasciitis, which prompted emergent debridement and intraoperative tissue biopsy. The wound began healing well with abundant granulation tissue (Figure 6), and she was discharged in good condition. Subcutaneous gas is associated with type I polymicrobial infections, particularly in patients with diabetes mellitus, and crepitus may be appreciated on exam.
Note: these are independent categories and do not necessarily represent chain of progression of disease.
The patient improved clinically over the next five days, and her WBC count trended downward to 15,000 per mm3.
Given the extent of the orbital involvement, plans were made for emergent exenteration of the right eye if necrotizing fasciitis was diagnosed in the operating room (OR).
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However, on the sixth day, the WBC count spiked to greater than 20,000 per mm3, prompting repeat CT imaging which showed fat stranding in the retrobulbar space as well as proptosis of the right eye (Figure 1). The presence of cytotoxins contributes to shock, organ failure, and tissue damage in patients with concurrent toxic shock syndrome (8).
Late in the infectious course, the patient will develop systemic signs and symptoms including fever, tachycardia, hypotension, and malaise. There was concern for worsening of her orbital cellulitis despite broad spectrum IV anitibiotics.
She was then transferred to the University of Iowa Hospital and Clinics (UIHC) for ophthalmologic evaluation. Initial cultures from her blood and periocular drainage grew group A beta-hemolytic streptococci. A prospective, observational study of 84 patients with invasive GAS infections performed between 2002-2004 found that adding IVIG to the antibiotic regimen reduced mortality from 15% to 7% (18). Patients should be treated at least until adequate surgical debridement is completed and the patient is hemodynamically stable (14). It is reasonable to pursue IVIG treatment in a patient in septic shock from GAS infection who has not responded to the traditional methods of treatment.

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