Conservative management of periorbital necrotizing fasciitis caused by methicillin-resistance Staphylococcus aureus

Necrotizing fasciitis (NF) of the periorbital region is a rare occurrence, though has been shown to cause severe facial disfigurement, blindness, and death.^, We report a case of community-acquired methicillin-resistant Staphylococcus aureus (MRSA)–associated periorbital NF in a 25-year-old woman, who presented with left eye and nostril redness and swelling after picking a pimple on her nose a few days prior. She had no significant medical history and was not diabetic. She was initially diagnosed with facial cellulitis and commenced on antibiotics, but returned 2 days later with worsening cellulitis, bilateral leg pain and redness, and shortness of breath. Within a day, she developed pneumonia and sepsis, and she was intubated and transferred to our unit. She was found to have MRSA on blood culture, and she was commenced on meropenem, vancomycin, and clindamycin. Ophthalmic examination while intubated showed left nose, cheek, and upper and lower eyelid redness and swelling. The swelling felt indurated without any evidence of crepitus or frank necrosis. She also had evidence of bilateral thigh cellulitis and was taken to theatre for urgent surgical exploration and debridement of the face and thighs.

Thigh debridement by Plastics revealed grey exudate and moderate muscle deterioration. Facial surgical exploration and debridement involved the left upper and lower eyelids, left nose, cheek, and temporal fossa, using a conservative, skin-sparing approach. This was possible as the skin appeared to be unaffected by necrosis. Surgical exploration revealed multiple, noncontiguous necrotic foci across different tissue planes. Necrotic tissue involving the orbicularis, tarsus, septum, orbital fat, orbital lobe of the lacrimal gland, and periosteum were excised from the mid-upper eyelid to the superotemporal orbital rim and lateral orbital rim/temporal fossa (Fig. 1A). Further nonviable tissue involving the skin was excised from the medial lower eyelid, cheek, and left nasal sidewall down to the bone (Fig. 1B). Histology confirmed the presence of necrotic soft tissue with heavy infiltration of gram-positive cocci on gram staining, which also grew MRSA (Fig. 2).

The patient underwent daily wound exploration and debridement of necrotic tissue from her face and thighs for 6 days until the wounds were judged to be clean. She remained intubated on intensive care unit during this time and had a protracted recovery in hospital owing to her pneumonia and sepsis. Postoperatively she was noted to have minimal orbicularis function and 6 mm lagophthalmos, and a left tarsorrhaphy was performed to prevent exposure keratopathy. Her final visual acuity was 6/12 in the left eye. She will undergo definitive reconstructive surgery to her upper eyelids and nasal defect in due course.

NF is a rapidly progressive and potentially fatal disease requiring urgent detection and decisive intervention in order to minimize the extent of irreversible tissue destruction and prevent death. The majority of NF infections involve the limbs, abdomen, and/or groin, whereas infection of the periorbita is comparatively rare and carries a more favourable prognosis.^,, This disparity in clinical course has been attributed to the unique anatomical features of the periorbita, with its relatively thin skin allowing earlier recognition of the disease, and abundant vasculature allowing better antibiotic penetration.^, Beta-haemolytic streptococcus is the major cause of periorbital NF, identified as the singular causative agent in around 50% of cases.^, Although S. aureus is often implicated alongside other pathogens in polymicrobial necrotizing infections, it is rarely identified as an isolated cause of NF (approximately 1% of periorbital NF cases).^,

With early recognition and intensive treatment, periorbital NF is associated with a lower incidence of sepsis and death, with minimal necrotic spread compared with more commonly involved sites.^, Although early and extensive debridement has long been considered vital in the management of NF, recent evidence has suggested that infections localized to the periorbita may be successfully managed with a less radical approach. In a 2002 study by Luksich et al., intravenous antibiotic therapy with or without delayed bedside debridement was successful in 5 patients with NF infections limited to the eyelids. All patients retained adequate or excellent lid function at follow-up, with adequate or excellent cosmetic appearance achieved in 3 cases. This method was successfully implemented by Schulz et al. in a further case complicated by extensive sinus involvement. The authors of both studies, however, stressed the importance of close observation and severe risks of complacency in such cases, given the latent potential for rapid progression and fatality.^, Our patient posed an additional operative challenge as surgical exploration revealed multiple, noncontiguous necrotic foci across different tissue planes, a feature that is not well described in the literature. This required careful exploration beyond the normal tissue seen at the edge of necrosis, and close daily monitoring of the wounds, to ensure adequate debridement. Hyperbaric oxygen and intravenous immunoglobulin have been reported as treatment options with some efficacy in the literature. However, both treatments remain controversial with a lack of high-quality, prospective studies to support their use. Additionally, hyperbaric oxygen was not available at our institution.

In summary, the periorbital region is a rare site of NF infection associated with lower mortality when compared with other sites, though significant morbidity with often devastating cosmetic outcomes. This case adds to a growing body of evidence to support the use of skin-sparing debridement in patients with periorbital NF, which can be successfully managed with a more conservative approach than required for other sites of infection.