Abstract
Cervical necrotizing fasciitis is a rapidly progressive and devastating infection that is usually caused by a polymicrobial infection including group A Streptococcus and anaerobes. We present a case of a newly diagnosed diabetic man who underwent transoral drainage of a Klebsiella pneumoniae paraglottic abscess, which, despite culture-directed antibiotics, progressed to cervical necrotizing fasciitis with descending mediastinitis. The patient required 12 surgical debridements and sternotomy, but survived and was discharged on hospital day 40. To our knowledge, this is the first case of cervical necrotizing fasciitis caused by a K pneumoniae infection in the United States. The significance of this unusual presentation is discussed.
1
Introduction
Cervical necrotizing fasciitis (CNF) constitutes up to 5% of all cases of necrotizing fasciitis, carries up to 40% mortality, and is traditionally linked to gram-positive predominant, polymicrobial infection [ ]. Cultures from CNF with a dental source are more likely to include anaerobes, whereas cases associated with pharyngeal mucosa or skin trauma more likely include Staphylococcus and Streptococcus species [ ]. Cervical necrotizing fasciitis caused by Klebsiella pneumoniae , however, is a rare entity that has not yet been reported in the Western hemisphere.
In our review of the literature, we found only 14 reported cases of necrotizing fasciitis associated with K pneumoniae , and all were primarily from Asia and the Middle East ; only 1 case was localized to the head and neck in a patient with AIDS . Only 2 cases of necrotizing fasciitis associated with K pneumoniae have been reported in the Western hemisphere; both occurred outside the head and neck and are linked to travel from Asia [ ].
2
Case report
A 31-year-old Samoan man presented with 36 hours of odynophagia, dysphagia, left-sided otalgia, and fevers. On examination, he demonstrated tenderness over the left neck and hoarseness, but no respiratory distress. Laboratory work was remarkable, with a white blood cell count of 10.4 × 10 9 /L, lactate level of 2.7 mmol/L, and glucose level of 17.87 mmol/L (322 mg/dL). Flexible fiber-optic laryngoscopy demonstrated left aryepiglottic fold, arytenoid, and false fold erythema and swelling, but normal vocal fold movement. Computed tomography (CT) with contrast of the neck demonstrated soft tissue edema in the left paraglottic region consistent with an early phlegmon. He was initially administered empiric ampicillin/sulbactam and dexamethasone for airway edema and was placed on an insulin drip. Symptomatic improvement and decreased hoarseness were noted over the next 3 days.
On hospital day 4, the patient complained of abruptly increased left neck pain and developed hemoptysis. Repeat imaging demonstrated a left paraglottic abscess. He underwent direct laryngoscopy and transoral exploration, with drainage of purulence from the left paraglottic region. Cultures grew K pneumoniae sensitive to ampicillin/sulbactam. After 3 days of initial symptomatic improvement, the patient acutely decompensated again and required emergent intubation. A neck and chest CT with contrast demonstrated extension of inflammatory changes throughout the cervical fascial planes bilaterally descending into the mediastinum as well as bilateral pleural effusions ( Fig. 1 ). Urgent cervical incision and debridement revealed necrotic strap and sternocleidomastoid musculature, confirming the diagnosis of CNF. Necrotic tissue was evacuated from the anterior cervical triangle, vascular space, and retropharyngeal space bilaterally.
Clindamycin, gentamicin, penicillin, and vancomycin were initiated per infectious disease consultation to broadly cover pathogens associated with necrotizing fasciitis. Anaerobic and aerobic serial wound and tissue cultures consistently grew K pneumoniae with mucoid phenotype, and antibiotics were narrowed to imipenem-cilastatin and vancomycin. It was unclear why the patient’s infection had progressed despite appropriate culture-directed antibiotic treatment throughout his hospital course. The patient underwent 12 debridements before ultimately being discharged on hospital day 40 on oral ciprofloxacin.
2
Case report
A 31-year-old Samoan man presented with 36 hours of odynophagia, dysphagia, left-sided otalgia, and fevers. On examination, he demonstrated tenderness over the left neck and hoarseness, but no respiratory distress. Laboratory work was remarkable, with a white blood cell count of 10.4 × 10 9 /L, lactate level of 2.7 mmol/L, and glucose level of 17.87 mmol/L (322 mg/dL). Flexible fiber-optic laryngoscopy demonstrated left aryepiglottic fold, arytenoid, and false fold erythema and swelling, but normal vocal fold movement. Computed tomography (CT) with contrast of the neck demonstrated soft tissue edema in the left paraglottic region consistent with an early phlegmon. He was initially administered empiric ampicillin/sulbactam and dexamethasone for airway edema and was placed on an insulin drip. Symptomatic improvement and decreased hoarseness were noted over the next 3 days.
On hospital day 4, the patient complained of abruptly increased left neck pain and developed hemoptysis. Repeat imaging demonstrated a left paraglottic abscess. He underwent direct laryngoscopy and transoral exploration, with drainage of purulence from the left paraglottic region. Cultures grew K pneumoniae sensitive to ampicillin/sulbactam. After 3 days of initial symptomatic improvement, the patient acutely decompensated again and required emergent intubation. A neck and chest CT with contrast demonstrated extension of inflammatory changes throughout the cervical fascial planes bilaterally descending into the mediastinum as well as bilateral pleural effusions ( Fig. 1 ). Urgent cervical incision and debridement revealed necrotic strap and sternocleidomastoid musculature, confirming the diagnosis of CNF. Necrotic tissue was evacuated from the anterior cervical triangle, vascular space, and retropharyngeal space bilaterally.
