Clusters of cases of invasive aspergillosis in transplant units: nosocomial spread or enhanced virulence?

derwent surgical exploration 48 h after admission to the hospital because of the rapid extension of the cutaneous lesions and the persistence of high fever, chills, and worsening sepsis. Initial surgical exploration revealed purulent collections of fluid and inflamed tissue alongside the deep fascias. S. pneumoniae was recovered from cultures of intraoperative wound aspirate specimens. The patient subsequently underwent daily surgical debridement because of persistent necrosis of skin and of subcutaneous tissue. On hospital day 19, a skin graft was performed; the patient made an uneventful recovery and was discharged on hospital day 24. Necrotizing fasciitis of the limbs following minor trauma is usually caused by bhemolytic streptococci or polymicrobial flora (aerobic and anaerobic) that include streptococci. S. pneumoniae is a distinctly unusual etiologic agent. It has been documented by results of cultures of blood samples or wound aspirates in a few reports [1, 2]. Most of the patients described in these reports had severe underlying disease and/or were immunocompromised because of drug abuse, diabetes, chronic renal failure, systemic lupus erythematosus, hypocomplementemia, or underlying coagulopathy. In several of these patients, necrotizing fasciitis appeared to be associated with the administration of systemic anti-inflammatory agents, either steroids or NSAIDs. The relationship between the systemic administration of NSAIDs and the risk of severe cutaneous infection has been debated in the literature since the 1980s [1, 3]. A recent case-control study of pediatric patients with varicella suggests that an increased risk of necrotizing fasciitis is associated with oral administration of NSAIDs to patients with cutaneous lesions [4]. Our patient did not take NSAIDs systemically but only applied them topically, which is an unusual circumstance to find associated with necrotizing fasciitis. In none of the previously described cases of necrotizing fasciitis were anti-inflammatory agents administered topically. The case we describe suggests that the caution applied to the use of systemic NSAIDs should be extended to the use of topical NSAIDs to treat patients who sustain minor trauma and have skin lesions.