Periorbital necrotizing fasciitis in adult and pediatric: Aftermath following two trivial traumas

Necrotizing fasciitis (NF) is a rapidly progressing, life-threatening infection requiring swift diagnosis and intervention to limit tissue damage and prevent death.[1] Periorbital necrotizing fasciitis (PNF), a rare subset of NF, affects the soft tissues around the eye and can lead to severe consequences, including facial disfigurement, blindness, or death.[2] While infections involving the limbs, abdomen, and groin are more common, PNF has a relatively better prognosis, though it still demands urgent treatment. This article discusses two clinical cases, highlighting the differences in adult and pediatric presentations of PNF, and emphasizes the importance of early intervention for optimal outcomes.[1–3] Case 1: 50-year-old Male A 50-year-old male chronic alcoholic presented with severe swelling and pain in his left eye five days after allegedly falling [Fig. 1]. Initially, he received wound repair and tetanus prophylaxis at a local hospital and was prescribed amoxicillin-clavulanic acid, NSAIDs, and Neosporin ointment. However, his symptoms worsened by the third day, and he sought further treatment. On examination, his right eye was normal, but his left eye exhibited severe periorbital edema, mechanical ptosis, skin excoriation, erythema, and pus discharge from the upper and lower eyelids. A CT scan of the orbit showed preseptal soft-tissue swelling with NF but no evidence of post-septal cellulitis or other complications.Figure 1: Clinical photograph of adult patient showing periorbital necrosed tissue on presentationAggressive treatment was initiated with intravenous cefotaxime, amikacin, and metronidazole. Pus samples were cultured, revealing Staphylococcus aureus as the causative agent. Daily wound debridement and packing were performed for five days. After a week of intravenous antibiotics, the patient was discharged on oral cephalexin and chloramphenicol ointment. By day 18, the wound had healed well with no further signs of infection or necrosis, and follow-up at day 30 showed full recovery with no lagophthalmos or ptosis [Fig. 2].Figure 2: Post treatment follow up on day 30Case 2: 3-year-old Female A 3-year-old female child presented with swelling, pain, and redness in her left eye for one week following trauma 10 days earlier when she was accidentally struck by a friend’s finger. The child was initially treated with tobramycin eye ointment and oral antibiotics, but her symptoms persisted. On examination, the child had significant periorbital edema, pus discharge, and mechanical ptosis in the left eye [Fig. 3]. Drainage of the pus was done immediately and sent for culture and sensitivity. Computed tomography (CT) scan revealed preseptal cellulitis with abscess formation and intra-orbital extension into the superolateral quadrant of the left eye.Figure 3: Clinical photograph of paediatric patient showing periorbital necrosis, abscess and pus discharge on presentationThe child was started on intravenous cefotaxime, and further incision and drainage were performed under anesthesia. Biopsy results indicated granulation tissue with no evidence of tuberculosis or malignancy. The culture identified Staphylococcus aureus. After five days of intravenous antibiotics, the child was discharged on oral cefotaxime and chloramphenicol ointment. On follow-up at 15 days, the left eye showed mild residual edema, but no discharge or further complications were noted [Fig. 4]. By the second follow-up at two months, both eyes were symmetrical, with normal vision in the right eye (6/6) and a slight reduction in the left (6/9).Figure 4: Post treatment follow up on day 60Discussion PNF is a rare but potentially devastating condition that involves rapid tissue destruction in the periorbital region. The incidence is higher among adults with compromised immune systems, such as diabetics, chronic alcoholics, and immunosuppressed individuals, or those with localized infections, such as sinusitis or dental caries. In children, PNF is less common but can result from viral illnesses (e.g., varicella) or minor trauma leading to direct inoculation of bacteria.[4,5] The clinical presentation in both age groups often mimics periorbital cellulitis, which is characterized by swelling, tenderness, and redness of the periorbital tissues.[6,7] As the infection progresses, more severe symptoms such as skin discoloration, blistering, and septic shock can develop, necessitating urgent intervention.[8] Imaging studies, such as contrast-enhanced CT or MRI, play a crucial role in diagnosing PNF by assessing the extent of soft-tissue involvement and guiding surgical intervention.[9] Histopathological examination, supported by microbial cultures, is considered the gold standard for diagnosis. In adults, polymicrobial infections, including anaerobic bacteria and gram-negative organisms, are common, while Group A Streptococcus is more frequently identified in pediatric cases. In the reported cases, both patients tested positive for Staphylococcus aureus, a common pathogen in PNF.[10] Prompt and aggressive management is essential for improving outcomes. This includes early surgical debridement to remove necrotic tissue, broad-spectrum intravenous antibiotics to control the infection, and supportive care to manage septic symptoms. Delayed intervention, especially in adults, is associated with poor outcomes.[11] Pediatric patients often fare better due to their stronger immune systems and more robust regenerative capacity, despite the rapid progression of the disease.[12] In both cases reported, early surgical intervention and targeted antibiotic therapy led to favorable outcomes. The adult patient showed significant improvement following a week of intravenous antibiotics and wound debridement, while the pediatric patient recovered quickly with minimal complications. The differences in the speed of recovery between the two cases reflect the general trend that children tend to have better prognoses due to their overall health and immune function.[13] Conclusion PNF is a rare but serious condition that can lead to life-threatening complications if not diagnosed and treated promptly. The cases presented highlight the importance of early detection and intervention, as well as the differing clinical courses in adults and children. In both age groups, periorbital infections that do not improve with standard treatments should raise suspicion for NF. Close collaboration between ophthalmologists, surgeons, and other specialists is essential for achieving the best possible outcomes. Authors' contributions Dr. Priyadarsini Nanda: Concept, Design, Definition of Intellectual Content, Literature Search, Clinical Studies, Data Acquisition, Data Analysis, Manuscript Preparation, Manuscript Editing, Manuscript Review; Dr. Anupam Singh: Concept, Design, Definition of Intellectual Content, Literature Search, Clinical Studies, Data Acquisition, Data Analysis, Manuscript Preparation Manuscript Editing, Manuscript Review; Dr. Usha Kim: Concept, Design, Definition of Intellectual Content, Clinical Studies, Data Analysis, Manuscript Editing, Manuscript Review; Dr. Vedant Sharma: Literature Search, Data Acquisition, Manuscript Preparation, Manuscript Editing, Manuscript Review; Dr. Ramya Ganesh: Literature Search, Data Acquisition, Manuscript Preparation, Manuscript Editing, Manuscript Review. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.