Sandeep Aggarwal, Karuna Thapar, Alok Goyal, Shashi Kiran Singh
Department of pediatrics, Government Medical College, Amritsar, Punjab, India

Keywords: septicemia, perforation, children

Septicemia is a systemic disease associated with the presence and persistence of bacteria and their toxins in the blood eventually leading to septic shock. Disfiguring permanent tissue damage due to septicemia is quite rare. We are reporting 2 cases of septicemia with perforation due to rarity of this complication.

Case no 1: A 21 days old female was admitted with lethargy, refusal to feed, fever, respiratory distress and abdominal distension. During stay in hospital, she developed convulsions and was investigated and treated on lines of septicemia with meningitis. During course of illness, she developed a reddish lesion over her upper part of nose, followed by ulceration at the same site. The ulcer was increasing in size despite treatment with broad-spectrum systemic antibiotics. Clinical examination revealed an erythematous, ulcerated plaque covered with brownish crusts. Removal of crust revealed a 0.5 x 0.5 cm sized perforation of the underlying cartilage into the both nasal cavities. The rest of nasal septum, lips and oral mucosa were normal. Biopsy from the ulcerated plaque was taken and special stains for acid-fast bacilli and fungi and bacterial, mycobacterial and fungal cultures were negative. Serology for syphilis, ELISA for human immunodeficiency virus (HIV), sputum for acid-fast bacilli and anti-nuclear antibodies were negative. After treatment with broad-spectrum systemic antibiotics, clinical improvement was observed within 2 weeks and at the end of therapy, the ulcerated plaque had completely resolved. A clean-looking perforation with healthy margin was present, which can be later surgically repaired.

Case no 2: A 3 months old female was admitted with lethargy, refusal to feed, fever, ulcerations in mouth, oral thrush, swelling over right mandibular region and malnutrition. During stay in hospital, she developed diarrhea and vomiting. She was investigated and treated on lines of septicemia. During course of illness, she developed a reddish lesion over her palate, followed by ulceration at the same site. The ulcer was increasing in size despite treatment with broad-spectrum systemic antibiotics. Clinical examination revealed an erythematous, ulcerated plaque covered with reddish black crusts. Removal of crust revealed a 0.6 x 0.5 cm sized perforation of the underlying cartilage. The rest of palate, lips and oral mucosa were normal. There was cervical lymphadenopathy and swelling over right mandibular region from which pus was drained later on. Blood culture, urine culture and pus culture showed klebsiella sensitive to amikacin, gatifloxacin and piperacillin +tazobactum. Biopsy from the ulcerated plaque was taken and investigations for acid-fast bacilli and fungi and bacterial, mycobacterial and fungal cultures were negative. Serology for syphilis, ELISA for human immunodeficiency virus (HIV), gastric lavage for acid fast bacilli and anti-nuclear antibodies were negative. After treatment with broad spectrum systemic antibiotics, clinical improvement was observed within 3 weeks and at the end of therapy, the ulcerated plaque had completely resolved. A clean-looking perforation with healthy margin was present, which can be later surgically repaired and closed for proper feeding.



The causes of nasal septal perforations include trauma, surgery, cocaine abuse, cauterization, infection, inflammation, and neoplasm. Among the inflammatory causes: Wegener's granulomatosis, systemic lupus erythematosis, sarcoidosis, rheumatoid arthritis, relapsing polychondritis, and Crohn's disease have been implicated. [1, 2]. Disfiguring permanent tissue damage like nasal septum perforation due to septicemia is quite rare.

Differential diagnosis of a lesion presenting as palatal perforation should include tertiary syphilis [3], leprosy, tantrum oris, mechanical trauma, intranasal cocaine abuse [4], malignancies, especially nasal T cell lymphomas, Wegener's granulomatosis and midline non-healing granuloma [5]. Septicemia as a cause of palatal perforation is quite rare.

Apart from its life threatening potential, septicemia can rarely lead to disfiguring permanent tissue damage. Hence there is need for early detection and treatment of septicemia in children.

1. Kuriloff DB. Nasal septal perforations and nasal obstruction. Otolaryngol Clin North Am 1989:22:333-50.
2. Baum ED, Boudousquie AC, Li S, Mirza N. Sarcoidosis with nasal obstruction and septal perforation. Ear Nose Throat J 1998;77:896-8,900-2.
3. VazquezJA: Zygomycosis, e.Medicine, 2002. Available at URL: www.e-medicine.com
4. Seyer B, Grist W, Miller S: Palatal perforation in long term intranasal cocaine abuse oral Surg Oral Med Oral Pathol Oral Radiol Endod, 94: 465-470, 2002
5. Loudon JA, Marsh WE, Allen CM: Destructive midline palatal lesion oral Surg Oral Med Oral Pathol Oral Radiol Endod, 89:134-136,2000

Last updated: 01-06-2009. Vol 6 Issue 6 Art # 32
Advance Access: 9th September 2008

Aggarwal S., Thapar K, Goyal A, Singh K. Perforation: A Rare Manifestation Of Septicemia. Pediatric Oncall [serial online] 2009 [cited 2009 ];6 Art # 32. Available from:
http://www.pediatriconcall.com/fordoctor/viewersChoice/septicemia.asp