Sunday, October 25, 2009 - 9:50 AM

Surgical Management of Deep Soft Tissue Infections in the Pediatric Patient

Shailesh Agarwal, BS and Lawrence J. Gottlieb, MD.

Background: Invasive soft tissue infections result in significant morbidity, and are often fatal without prompt medical and surgical attention.  Immunosuppressed and neutropenic patients are particularly susceptible to infection due to their immunologic state, and neutropenic patients frequently do not show the typical signs of inflammation or infection early in the course of soft tissue infections. Thus, their detection and treatment requires vigilance on the part of the pediatric team and communication with surgeons.  Here we report on the surgical management of invasive soft tissue infections in immunosuppressed or neutropenic pediatric patients at a single institution.

Methods:  This study is a retrospective chart review of patients less than 25 years old diagnosed with invasive soft tissue infections since January 1, 1998 and treated by the senior author at the University of Chicago. 

Results:  A total of 13 patients met criteria for inclusion with age ranging from 58 days to 24 years (mean: 11 years).  Underlying diagnoses were malignancy with chemotherapy (9), prematurity (2), and immunosuppression secondary to chronic disease (2).  Nine patients were neutropenic.  Localizing symptoms were observed in all patients, and included tenderness, erythema, and/or presence of bullae, purpura, or necrotic tissue. Other documented symptoms included fever (5) or signs of sepsis (e.g. hypotension) (3).  Three patients with malignancy had infection in proximity to chemotherapy port.  Organisms isolated from the wound included P. aeruginosa (5), E. coli (2), Gram-positive cocci (3), MRSA (1), and E. cloacae (1).  Septic microthrombi were found in 9 patients.  The number of required procedures ranged from 1 to 15.  Overall survival was 77% (10/13). Two patients died of complications related to infection, and 1 related to underlying malignancy; 2 patients required amputation (ear and leg).

Conclusions: Our experience indicates that invasive soft tissue infections can result in morbidity/mortality ranging from structural deficits amenable to reconstruction, to amputation or death.  While many patients showed only subtle signs of infection, surgical investigation in all patients revealed widespread subcutaneous and muscular extension. We also noted a decreased magnitude of debridement in the later part of the study and attribute this to improved communication with pediatric oncologists resulting in earlier surgical consultation. A high index of suspicion by the pediatric team and communication with the surgical team are required to avoid the complications of invasive, soft tissue infections.

Figure: Left, 4-year old male with right subclavian vein chemotherapy port with drainage from port and purpuric lesions.  Right, Debridement extends through subcutaneous tissue with muscle sparing.