Case Report: Diagnostic and management challenges of necrotizing fasciitis in an immunocompromised child with acute lymphoblastic leukaemia.
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Necrotizing fasciitis (NF) is a rare, rapidly progressive soft-tissue infection that, when compounded by an immunocompromised state, increases susceptibility, severity, and diagnostic difficulty. Furthermore, reconstruction of the resulting defects is particularly challenging in neutropenic patients. Skin allograft offers a temporary biological cover that may be especially advantageous in this setting. We describe its use in a child with relapsed Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph + ALL) who presented with NF of the perineum while on chemotherapy. A 4-year-old boy with relapsed Ph + ALL on a high-risk chemotherapy protocol presented with neutropenic fever and decompensated septic shock. Despite resuscitation and broad-spectrum antibiotics, he deteriorated, requiring intensive care. A perianal swelling initially attributed to cellulitis progressed, and rapid clinical deterioration raised suspicion of perineal NF. He underwent emergency exploration, which revealed extensive non-viable tissue of the perineum, bilateral inguinal regions, and thigh; serial debridement and a diverting colostomy were performed, with tissue cultures yielding Proteus mirabilis sensitive to cefepime and meropenem. Reconstruction was staged with negative-pressure wound therapy and human skin allograft. Allograft was preferred over autograft because the child was physiologically unstable with an unhealthy wound bed, and because delayed allograft rejection in the immunosuppressed permits prolonged engraftment. The wound healed over 5 months, and the stoma was reversed at 5 months. Skin allograft served as an effective temporary biological dressing that prepared the wound bed and promoted healing while avoiding the donor-site morbidity of an autograft in a critically ill child, with immunosuppression likely favouring prolonged engraftment. This case adds to the limited evidence supporting allograft as a useful adjunct for staged wound closure in immunocompromised children with NF. NF in immunocompromised children is easily missed and demands a high index of suspicion and prompt surgical control. Skin allograft is a useful, well-tolerated adjunct for staged wound closure in this group, avoiding donor-site morbidity in a critically ill child; larger studies are needed to define its role.