CASE REPORT Open Access

Fulminant necrotizing fasciitis following the useof herbal concoction: a case reportIsmaila A Adigun1,2, Abdulrasheed A Nasir2*, Adebiyi B Aderibigbe2

Abstract

Introduction: Necrotizing fasciitis is a rare and life-threatening rapidly progressive soft tissue infection. A fulminantcase could involve muscle and bone. Necrotizing fasciitis after corticosteroid therapy and intramuscular injection ofnon-steroidal anti-inflammatory drugs has been reported. We present a case of fulminant necrotizing fasciitisoccurring in a patient who used a herbal concoction to treat a chronic leg ulcer.

Case presentation: A 20-year-old Ibo woman from Nigeria presented with a three-year history of recurrent chroniculcer of the right leg. She started applying a herbal concoction to dress the wound two weeks prior topresentation. This resulted in rapidly progressive soft tissue necrosis that spread from the soft tissue to the bone,despite aggressive emergency debridement. As a result she underwent above-knee amputation.

Conclusion: The herbal concoction used is toxic, and can initiate and exacerbate necrotizing fasciitis. Its use forwound dressing should be discouraged.

IntroductionNecrotizing fasciitis (NF) is a rare but fatal rapidly pro-gressive soft tissue infection, which is characterized bywidespread necrosis of the superficial fascia and the sub-cutaneous fat. NF spreads along the fascia plane usuallysparing surface skin and the muscle but fulminatingcases can affect the muscle. NF is associated with highmortality and long-term morbidity [1,2]. Early clinicalsuspicion of necrotizing fasciitis is crucial becausepatient survival is inversely related to the time betweenthe onset of infection and the initiation of appropriatetherapy [1]. Fulminating necrotizing fasciitis after corti-costeroid therapy [3] and intramuscular injection ofnonsteroidal anti-inflammatory have been reported [2].Fulminant necrotizing fasciitis from an herbal concoc-tion has not been reported in English-language medicalliterature. We present a case of fulminating NF thatoccurred after the use of an herbal concoction.

Case presentationA 20-year-old Ibo undergraduate woman presented witha three-year history of recurrent chronic ulcer of the

right leg. Upon presentation there was associated legpain and progressive leg swelling of three days duration.The leg ulcer had started increasing progressively in sizefollowing the use of an herbal concoction the patientused to dress the wound two weeks prior to presenta-tion. She had had two previous skin grafts. She, how-ever, had not attended a follow-up appointment. Uponpresentation she was a young, overweight woman, toxicand dehydrated. She was febrile with a temperature of38.2°C, had tachypnea, and was jaundiced with bilateralpitting pedal edema which was worse on the right legup to the thigh. She had a regular pulse of 132 beats perminute with blood pressure of 90/50 mmHg. Therewere multiple ulcers on the right leg. The floor of theulcers contained slough with purulent discharges. Thedorsalis pedis was not palpable on the right side. Thepacked cell volume was 20% and serum electrolyteswere normal. She was resuscitated with 0.9% normal sal-ine, intravenous antibiotic ceftriazole 1 g every twelvehours, metronidazole 500 mg every eight hours. She wastransfused with three units of blood. Initial fasciotomywas performed with no significant improvement. Shedeveloped widespread skin necrosis and palpable crepi-tus on her right foot up to the upper third of her leg(Figure 1). She had emergency radical debridement ofthe anterior, lateral and part of the posterior

* Correspondence: draanasir@yahoo.com2Department of Surgery, University of Ilorin Teaching Hospital, PMB 1459,Ilorin, NigeriaFull list of author information is available at the end of the article

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CASE REPORTS

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compartments of the right leg on the fourth day follow-ing admission. Intraoperative findings were large intra-muscular abscesses, and myonecrosis of thegastrocnemius and the tibialis anterior muscle, whichwere debrided (Figure 2). She was treated with a honeydressing and serial debridement. There was, however,progressive necrosis involving the tibia and fibula up tothe level of her knee (Figure 3) and she became septic.She then underwent above-knee amputation (AKA) ofthe right extremity. Culture of the wound biopsy yieldedmixed growth of Klebseilla and Pseudomonas. Histologyof the debrided tissues showed fibromuscular and fibro-fatty tissue with extensive necrosis and a focal collectionof mononuclear inflammatory cells. She did well post-operatively and she is being prepared for prosthesis.

DiscussionNecrotizing soft tissue infections are characterized byrapid progression of infection with soft tissue destruc-tion and are associated with high long-term morbidity

and mortality [1,2]. When muscle necrosis is involved,like that in the patient presented, the term myonecrosisis used [1]. NF can be initiated after surgical procedures,minor trauma, trivial scratches, or in the setting of achronic wound, but may occur spontaneously or afterminor injury in an otherwise healthy person [4,5]. Indeveloping countries, an herbal concoction of unknowncomposition is used for various purposes but its use totreat wounds is uncommon. It is toxic and highly con-taminating, and can initiate and exacerbate progressionof soft tissue infection. Its use can lead to progressivenecrosis in the patient. No case of amputation wasrecorded in the previous report by Adigun et al fromthe University of Ilorin Teaching Hospital [6]. The cau-sative organisms are usually mixed and are toxin-produ-cing, virulent bacteria, including Streptococcus,Staphylococcus, or a combination of Gram-negativebacilli and anaerobes [4,7]. Mixed growth of Klebseillaand Pseudomonas were cultured in our patient. Presen-tation is usually non-specific with minimal local mani-festations. Symptoms are fever, leg pain and swelling, orearly cutaneous signs including edema, erythema, localanesthesia and occasional crepitus. Despite the minimallocal manifestations, the patients usually complain ofsevere pain. Pain out of proportion to the physical find-ings in a patient with systemic toxic signs should raisethe clinical suspicion of necrotizing fasciitis [8]. In thelate stage of the disease, the infection is disseminatedthrough the relatively avascular fascia planes. It causesthrombosis of the affected blood vessels and devasculari-sation of the overlying skin. As organisms and toxins arereleased into the bloodstream, sepsis invariably develops[9]. The unexpected fulminant clinical course may pointto diagnosis of myonecrosis as in this patient presentedwith progressive necrosis and sepsis despite initial fas-ciotomy and debridement. When necrotizing myositis issuspected, gross muscle necrosis can be confirmed byradiological imaging, such as computerized tomography

Figure 1 Right leg showing progressive skin necrosis up to theupper third of the leg, with incision of initial fasciotomy onthe dorsum of the foot and distal leg. This was on the third dayafter admission.

Figure 2 Right leg immediately after initial radicaldebridement showing well vascularised soft tissue on thefourth day after admission.

Figure 3 Progressive right leg tissue necrosis involving thetibia and fibula a week after initial debridement.

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and magnetic resonance imaging [1]. These technologiesare not available in our center. The mainstay of treat-ment of all necrotizing soft-tissue infections is earlyradical debridement of all necrotic tissue. Fulminatingcases may require amputation of the affected extremity.Clinical suspicion must prompt immediate surgicalintervention with aggressive debridement and appropri-ate antibiotic therapy.

ConclusionThe herbal concoction the patient used is a highly toxiccontaminant that can lead to fulminating soft tissueinfection. The use of this herbal concoction for woundcare should be discouraged. An aggressive early surgicaldebridement is needed to prevent unnecessaryamputation.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompany-ing images. A copy of the written consent is availablefor review by the Editor-in-Chief of this journal.

Author details1Division of Plastic and Reconstruction Surgery, Department of Surgery,University of Ilorin Teaching Hospital, PMB 1459, Ilorin, Nigeria. 2Departmentof Surgery, University of Ilorin Teaching Hospital, PMB 1459, Ilorin, Nigeria.

Authors’ contributionsIAA operated on the patient and was a major contributor in writing themanuscript. AAN wrote the initial and final drafts, and did the revision of themanuscript and carried out the literature search. ABA wrote the casesummary and was a major contributor in writing the manuscript. All authorsread and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 7 January 2009 Accepted: 19 October 2010Published: 19 October 2010

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doi:10.1186/1752-1947-4-326Cite this article as: Adigun et al.: Fulminant necrotizing fasciitisfollowing the use of herbal concoction: a case report. Journal of MedicalCase Reports 2010 4:326.

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