Necrotizing Fasciitis After Acupuncture in a Patient with Aplastic Anemia

Introduction

A ccording to Traditional Chinese medicine, there are two complementary factors that coexist in nature: Yin and Yang, and a vital energy called Qi, which is essential for good health, flows through the human organs. The ancient Chinese believed that Qi flows through a network in the body composed of meridians, and that acupuncture along points of these meridians can balance energy circulation throughout the body. Complementary and alternative medical therapies are increasingly popular in Western countries, with the growing belief that “natural” treatments are safer and better, ¹ especially acupuncture. ² Acupuncture is believed to be a relatively safe procedure when performed by qualified acupuncturists. ³ However, in this report, a rare and serious complication of acupuncture is described in a high-risk patient (i.e., necrotizing fasciitis in a patient with aplastic anemia).

Case Report

A 44-year-old woman with aplastic anemia experienced right calf pain after running. She had received immunosuppressive treatment (prednisolone 5 mg per day) for 4 months and had stopped treatment for 1 month prior to this event. She had no other cormobidities such as hypertension, diabetes mellitus, renal insufficiency, atherosclerosis, or cirrhosis. She received physical therapy at a local clinic for 10 days but the pain continued. She then received one session of needle acupuncture treatment at a Traditional Chinese Medicine clinic. The acupuncture was performed by a traditional Chinese medical doctor using alcohol swabs (containing isopropyl alcohol 70%) locally over the skin of the right calf. Four (4) disposable, sterilized, and individually wrapped stainless-steel needles (0.25 mm in diameter, 50-mm length) were inserted into the tender area of the right calf. The needles were inserted to a depth where the patient can typically experience a sensation known as de qi (a subjective soreness, fullness, and numb feeling around the acupuncture points). The needles were inserted for 20 minutes. There was no potentiation with moxibustion or electroacupuncture. However, progressive pain and swelling of the right calf developed 2 days later, so that she could not walk.

She was admitted 10 days later to our hospital, initially for pain and swelling of the right calf muscle. Fever started on admission day. On admission, she had a temperature of 38.8^o C, a heart rate of 80/min, and blood pressure of 112/70 mm Hg. Physical examination showed signs of swelling with local tenderness, heat, and reddish skin at the site where the acupuncture needle was inserted and the whole right calf. Limited active dorsiflexion of the right ankle was also noticed. Laboratory analysis showed a white blood cell count of 500/μL and hemoglobin of 5.7 g/dL. She was transferred to an isolation room.

Under the impression of cellulitis, the antibiotic oxacillin (2 g every 6 hours) was administered by intravenous injection on an empirical basis as suggested by an infection specialist in our hospital the first day of admission. A nerve conduction study showed no evidence of peroneal neuropathy. Granulocyte colony-stimulating factor (300 μg per day) by subcutaneous injection was started 1 week after admission. However, she experienced intractable pain and the skin developed reddish patchy discoloration with ill-defined margins. No sign of tissue necrosis and/or gangrenous skin was ever present. Because of its progressive and rapidly spreading course, necrotizing fasciitis was strongly suspected. A computed tomography (CT) scan of the right leg showed edematous changes infiltrating the deep fascial plane with fluid collecting in the medial gastrocnemius muscle. Surgical debridement of the necrotic tissues, such as subcutaneous tissue, fascia, and muscles, was suggested but refused by the patient. Ultrasound examination revealed marked hypoechoic fluid accumulation in the fascia of the right medial gastrocnemius muscle. Ultrasound-guided needle aspiration of the fluid in the right medial gastrocnemius fascia produced yellow–reddish mucoid fluid. Aerobic bacterial culture of the fluid revealed Staphylococcus aureus infection with in vitro susceptibility to oxacillin.

Based on the diagnosis of necrotizing fasciitis, the previously described antibiotic treatment was continued for a total of 18 days. The fever and the swelling of the right calf gradually subsided. The antibiotic administered was changed to oral cloxacillin (1000 mg every 8 hours). She was discharged after 21 days.

Discussion

Acupuncture has been performed in China for more than 3500 years by inserting needles into acupoints or symptomatic areas. Acupuncture can activate A-delta and C afferent fibers in muscles, stimulate the release of neurochemicals such as endorphins, enkephalins, dynorphins, and serotonin by activation of the spinal cord, midbrain, and pituitary centers. It also can alter the sympathetic and parasympathetic nervous system and increase local blood flow and nitric oxide release. ^{4 –6}

The most commonly seen complication of acupuncture is “needle shock reaction” (fainting), which is not life threatening. ⁶ It is estimated that serious adverse events occur in 0.55 per 10,000 acupuncture treatments. ⁷ However, rare complications that are more serious have also been reported, including infection (e.g., cellulitis, abscess, hepatitis, endocarditis, and so on) and mechanical injuries (e.g., pneumothorax, cardiac tamponade, spinal cord injury, pseudoaneurysm rupture, necrotizing aortitis, and needle migrating to the medulla oblongata). ^{6,8 –13} High-risk patients, such as those with hematological disorders, poor cognitive function, or immunodeficiency are not good candidates for acupuncture intervention. In addition, subjects with “needle phobia” may not tolerate the procedure. ⁶

Necrotizing fasciitis as a complication of acupuncture has been reported in a patient following acupuncture procedures performed with a single needle heated over a candle, with the skin cleaned with a wet cloth only. ¹⁴ In Taiwan, prevention of complications such as are described in this case study is one reason that acupuncture procedures should be performed by traditional Chinese doctors or qualified physicians with acupuncture therapy certification. Traditional Chinese doctors receive acupuncture training during a 6-year program in college. Qualified physicians who graduate from 7-year medical programs should receive an additional 6 months of acupuncture training and certification for performing acupuncture procedures. Unfortunately, complications such as serious infections still happen to aplastic anemia patients. The patient herself not informing the acupuncturist of her underlying disease (in this case, aplastic anemia), and lack of detailed medical history taking by acupuncturists at local clinics may both have contributed to the serious complications in this case. Acupuncturists, whatever their background, must inquire about serious illnesses, such as aplastic anemia. Therefore, extreme caution should be taken in the form of detailed medical history taking to identify high-risk patients and to avoid performing acupuncture on poor candidates.

This case constitutes a health care–associated infection. It is estimated that 5%–19% of hospitalized patients worldwide acquire infections associated with health care. ¹⁵ Such infections result in prolonged hospital stays, additional costs for health systems, increased microorganism resistance to antimicrobials, greater stress among patients and family, and excess mortality. ¹⁵ The risk posed by health care–associated infection depends on factors such as the infectious agent (and antimicrobial resistance), the host (especially high-risk patients, such as the elderly, those with underlying comobidities, immunocompromised patients, and so on), and the environment (such as invasive acupuncture procedures and intensive care units admission). ¹⁵ High-risk patients are at greatest risk for infection by airborne microorganisms. ¹⁶ A protective environment with a positive airflow relative to the corridor can create a safe environment for specialized patient-care ¹⁶ such as performing acupuncture procedures. The concept of “clean care,” such as appropriate hand hygiene before and after touching patients and before performing invasive acupuncture procedures, and local skin cleaning with alcohol swabs (containing isopropyl alcohol 70%), must be strongly encouraged among health care workers who perform acupuncture procedures.

Necrotizing fasciitis is a life-threatening infection involving superficial fascia, subcutaneous tissue, and deep fascia. ¹⁷ The incidence of necrotizing fasciitis is reported to be 0.40 cases per 100,000 people, occurring among males slightly more often. ^18,19 There is no age predilection for necrotizing fasciitis. ¹⁹ It is characterized by infection along the fascial planes resulting in necrosis and suppuration of fascia and soft tissue, and even thrombosis of vessels. ²⁰ Toxic substances and enzymes released by bacteria contribute to local tissue destruction and advance to systemic sepsis and fatal organ failure. ²⁰ Necrotizing fasciitis may result from soft-tissue trauma, insect bites, subcutaneous injections, blunt trauma, muscle strains, surgical procedures ^{19 –21} and, as demonstrated in this report, acupuncture. Group A β-hemolytic streptococci and, as in this case, staphylococci, are commonly noted in patients with history of skin and soft-tissue trauma. ¹⁹ The infection is also commonly associated with pre-existing conditions, such as diabetes mellitus, hypertension, renal insufficiency, cancer, cirrhosis, immunosuppression, underlying malignancy, and age over 65 years ^19,21

Most patients with necrotizing fasciitis first presented with fever and signs of inflammation, such as skin with erythema, swelling, induration, skin anesthesia, and cellulitis at the affected site. ²² As the disease progresses, the skin becomes tense, shiny, smooth, and swollen, with indistinct margins and severe pain disproportionate to the physical findings. ^18,19,22 Late findings include skin discoloration, blistering, hemorrhagic bullae, crepitus, discharge of “dishwater” pus, severe sepsis, or multiorgan failure. ^18,19,21,22 The duration and presentation of symptoms vary clinically. ¹⁹ The clinical signs should be distinguished from other soft-tissue infections, such as cellulitis with infection involving the skin and subcutaneous tissues and common superficial pyodermas with local skin lesions and infections (erysipelas, impetigo, folliculitis, ecthyma, furunculosis, carbunculosis, and candidal septisemia). ^17,23

The diagnosis of necrotizing fasciitis is extremely difficult and relies on highly suspicious signs and symptoms, and remains primarily a clinical one. ¹⁹ As in this case, high-risk patients with gradually developed indistinct swollen skin and disproportionate pain present the clinical profile for suspecting necrotizing fasciitis. Although the laboratory risk indicator for necrotizing fasciitis scores, ²⁴ needle aspiration and incisional biopsy ¹⁹ have been used to aid clinical diagnosis, false-negative results have limited their clinical usefulness. ¹⁹ Reliable diagnostic aids for necrotizing fasciitis include CT and magnetic resonance imaging, which can visualize fluid collection with edematous changes infiltrating deep fascia and postcontrast enhancement; also, soft-tissue ultrasound shows fluid accumulation in the deep fascia. These imaging methods can delineate the extent of infection and can be performed safely and conveniently by qualified physicians. ^19,20,22

Antibiotics and surgical debridement (not performed in this case) are the treatments of choice for necrotizing fasciitis. ^18,19,21,22 Because most infections are polymicrobial, early administration of broad-spectrum antibiotics that also cover anaerobic organisms is recommended. The antibiotics should be adjusted according to the results of wound culture, Gram stain, and sensitivity. ^18,22 In this case, the antibiotics were started on an empirical basis following the initial diagnosis of cellulitis, and were continued based on proper etiological investigation with cultures resulting in the diagnosis of necrotizing fasciitis. Intravenous immunoglobulin has been shown to reduce the mortality among patients with toxic shock. ^21,22 The mortality associated with this infection ranges from 5% to 74%. ²²

Acupuncture has become popular for pain management in clinical practice. It is generally considered to be a safe procedure. However, the present case illustrates that serious complications do occasionally happen, especially among high-risk patients, such as those with aplastic anemia. It is common medical knowledge that patients with low white blood cell counts are prone to infection, and percutaneous procedures are associated with risk of infection. The authors advise that acupuncture not be absolutely contraindicated in patients with aplastic anemia; however, extreme precautions should be taken. Great caution should be performed when using acupuncture for high-risk patients, in the form of detailed medical history taking, careful selection of acupuncture sites, clean care, use of disposable, sterilized needles, and even performing acupuncture by transcutaneous procedures.

Conclusions

In conclusion, acupuncture should be performed using clean care practices, and necrotizing fasciitis must be considered as a possible complication in high-risk patients. Early recognition and treatment of this life-threatening soft-tissue infection is an important responsibility.