Periorbital necrotising fasciitis.

Periorbital necrotising fasciitis is an uncommon suppurative condition seen following trauma or in debilitated patients and frequently requires extensive debridement.' The basic pathological process is a cellulitis followed by suppuration and necrosis of the subcutaneous tissues and spread along the fascial planes of the sub-muscular aponeurotic system.2 The most frequently responsible pathogenic organism is the group A j haemolytic Streptococcus although other pathogens have been implicated. A case in a previously healthy man which resolved on antibiotic and steroid therapy is presented. Case report A 78-year-old man presented with a 24 hour history of acute periorbital swelling associated with severe pain. He had had an immediately preceding febrile illness and felt unwell with episodes of rigor and sweating. There was no previous ophthalmic or medical history of note. On examination he had a mild pyrexia, peri-orbital oedema with discharge from both eyes and was admitted with a provisional diagnosis of bilateral preseptal cellulitis. After conjunctival swabs and blood cultures he was started on intravenous doses of flucloxacillin and ampicillin. Over the next 48 hours the periorbital swelling worsened with ulceration and soft tissue necro-sis, a purpuric rash thought to be due to a secondary immune vasculitis developed over the dorsum ofboth feet and ankles (Figs 1, 2), and he became neutropenic with a white cell count of 2-2 x 109/l. Prednisolone was commenced at 60 mg/day. He was transferred to the eye unit and further tests showed an erythrocyte sedimentation rate of 70 mm/hour, with protein electrophoresis showing a polyclonal increase in gamma-globulins. Other investigations including radiography (and later computed tomography) of the sinuses and orbit, an autoimmune screen, and creatine kinase levels were within normal limits. A subsequent full blood count showed a partial resolution of the neutropenia and his general condition started to improve, his rash settled, and the periorbital swelling and necrosis began to subside. Ampicillin was replaced by penicillin after cultures grew group A ,3 haemolytic Streptococcus and Staphylococcus aureus, and after 1 week his prednisolone was slowly decreased and tapered down over 4 weeks. His antibiotics were continued and the necrotic crust on the right upper lid sloughed away at 4 weeks (Fig 3) with the left 2 weeks later. Raw areas healed by secondary intention and at 10 weeks he had minimal scarring, good lid closure, no trichiasis, and only slight thickening of the upper epicanthic folds (Fig 4). Comment There have been 19 …