Group A streptococcus is responsible for a diverse range of soft tissue infections. Manifestations range from minor oropharyngeal and cellulitic skin infections to more severe conditions such as necrotizing fasciitis and septic shock. Troubling increases in the incidence and the severity of streptococcal infections have been reported over the past 25 years. Cases of streptococcal necrotizing fasciitis have received significant attention in the literature, with prompt surgical debridement being the mainstay of treatment. However, cases of rapidly progressing upper extremity streptococcal cellulitis leading to shock and a subsequent surgical intervention have not been well described.
This article presents a case of an 85-year-old woman with a rapidly progressing, erythematous, painful, swollen hand associated with fever, hypotension, and mental status change. Due to a high clinical suspicion for necrotizing fasciitis, the patient was rapidly resuscitated and underwent immediate surgical irrigation and debridement. All intraoperative fascial pathology specimens were negative for necrotizing fasciitis, leading to a final diagnosis of Group A streptococcal cellulitis. Although surgical intervention is not commonly considered in patients with cellulitis, our patient benefited from irrigation and debridement with soft tissue decompression. In cases of necrotizing fasciitis as well as rapidly progressive cellulitis, prompt diagnosis and aggressive treatment may help patients avoid the catastrophic consequences of rapidly progressive group A streptococcal infections.
Group A streptococcus is responsible for a diverse range of soft tissue infections. Manifestations range from minor oropharyngeal and cellulitic skin infections to more severe conditions such as necrotizing fasciitis and septic shock. Troubling increases in the incidence and the severity of streptococcal infections have been reported over the past 25 years.1-3 Beginning in the late 1980s, a resurgence of invasive group A streptococcus was reported from both Europe and the United States with recent estimates suggesting that the incidence of these infections is 3 to 3.5 cases per 100,000 people.2,4
Cases of streptococcal necrotizing fasciitis have received significant attention in the literature, with prompt surgical debridement being the mainstay of treatment.3,5,6 However, cases of rapidly progressing upper extremity streptococcal cellulitis leading to shock and surgical treatment have not been well described. Differentiating an aggressive cellulitis from a true necrotizing fasciitis may be unnecessary because immediate surgical debridement can improve outcome in both cases. This article presents a case of an 85-year-old woman with Group A streptococcal cellulitis requiring surgical debridement.
An 85-year-old woman presented with fevers, generalized weakness, and progressive right arm erythema and pain. The family reported that the patient lacerated the dorsum of her hand a few weeks prior with a serrated knife while cutting a chicken but had no other history of trauma to the affected limb. The night before admission, the patient and her family noted a small, erythematous, warm area over the dorsum of her third metacarpophalangeal joint. The following morning, the patient was confused, with erythema now tracking proximally over the dorsum of her forearm, with a small area of erythema at the thoracic border of the axilla. Within 30 minutes, the erythema had tracked several centimeters and the patient became slower to respond. The family reported no recent travel, or insect or animal exposure. Her medical history was significant for psoriasis for which she received a dose of methotrexate 2 weeks earlier.
The patient was febrile to 101.9°, had a pulse of 76, respiratory rate of 20/min and blood pressure of 72/56. Oxygen saturation was 97% on room air. The patient was in mild distress, visibly tachypneic. She was oriented to self, place, and time but was lethargic and at times appeared obtunded however remained arousable. Cardiac examination was unremarkable for murmurs. Examination of her right upper extremity revealed significant soft tissue swelling, erythema, and ecchymosis about the dorsum of the right hand, extending from just distal to the metacarpophalangeal joints to approximately 6 cm proximal to the proximal wrist crease. The patient’s fingers were held in a position of partial flexion and passive movement causing her considerable pain. The hand and forearm were exquisitely tender with no appreciable crepitus, necrotic areas, or soft tissue masses. The patient had limited active range of motion of her fingers. There was also a small, 2×2-cm erythematous, tender area about the inferomedial aspect of the axilla in contiguity with the thoracic chest wall.
Two intravenous lines were immediately placed and 1 liter of normal saline was administered as a bolus. Portable radiographs revealed significant soft tissue swelling about the dorsum of the hand and forearm, with no subcutaneous gas or evidence of osteomyelitis. Labs and blood cultures were obtained. Laboratory values were negative for any signs of coagulopathy, renal dysfunction, or hepatic dysfunction. Intravenous doses of clindamycin, vancomycin and ampicillin/sulbactam were administered. The patient’s hypotension subsequently worsened with systolic pressures falling to the 60’s and continuously requiring vasopressors and fluid boluses to maintain perfusion pressures. A Foley catheter yielded only 40 cc of urine. She was cognitive throughout her time in the emergency room, although she became less alert and slower to respond. Within approximately 30 minutes, the erythematous area had progressed proximally approximately 1 to 2 cm.
The patient was admitted to the intensive care unit and arterial and central venous access was obtained. Given the rapid progression of symptoms and septic shock and a concern for necrotizing fasciitis, the patient underwent emergent irrigation and debridement. A 10-cm incision was made longitudinally on the dorsal aspects of the hand and forearm and a copious amount of edematous, dishwater pus was expressed from the subcutaneous tissue suggestive of fatty necrosis. Fluid was cultured and dissection was carried out to the dorsal enveloping fascia. No purulence or gross abscesses were noted. The dorsal fascia was then sharply débrided and excised, and then sent for frozen section and Gram stain. The underlying musculature appeared pink and viable, with no evidence of necrosis (Figure 1). The area was then copiously irrigated and the wound on the dorsum of the hand was loosely closed with nylon sutures to cover the exposed extensor tendons, and the wound with moist bandages. The general surgery team then performed debridement of the axillary region, with similar findings to the arm.
|Figure: Intraoperative image demonstrating the initial area of erythema over the dorsum of the hand and forearm. The muscle and fascia do not have definitive areas of necrosis; however fatty necrosis appears along the ulnar aspect just proximal to the wrist. |
Postoperatively, the patient was continued on broad-spectrum antibiotics.
Preoperative blood cultures and intraoperative fluid cultures revealed beta-hemolytic group A Streptococcus (Pyogenes), positive for pyrogenic exotoxins B and C, and antibiotics were tailored appropriately. Pathologic evaluation of the fascia revealed viable fibroconnective tissue with no evidence of bacterial colonization, inflammation, or necrosis. Another irrigation and debridement was performed the following morning. Again, there was no clinical evidence of fascial necrosis intra-operatively. Over the next few days, the patient improved hemodynamically and clinically with regard to mental status and was subsequently extubated. On hospital day 5, the plastic surgery team covered the wound with a 120 cm2 split-thickness skin graft and a vacuum dressing was applied. The patient was subsequently discharged home to complete a course of intravenous penicillin G.
Cellulitis is a common skin infection associated with areas of skin erythema, soft tissue edema, and warmth. Risk factors include a disruption of the cutaneous barrier, lymphedema, venous insufficiency, immunosuppression, and being overweight.7 Cellulitis is encountered in both outpatient and hospital settings and is generally associated with limited mortality. Although rare, cases of cellulitis can be associated with more serious local complications including surgical debridement and amputation as well as hospital complications such as nosocomial infections, hyperglycemia, hepatic encephalopathy and heart failure.8 Additionally, necrotizing fasciitis may present similarly to cellulitis. Clinical signs thought to differentiate necrotizing fasciitis from cellulitis (hemodynamic instability, crepitus, skin necrosis, bullae, and subcutaneous gas on radiograph) are unfortunately not present in all patients. Callahan et al9 found absence of these signs on presentation in 25 of 30 patients later diagnosed with a necrotizing soft tissue infection.
Other modalities to aid in the diagnosis of necrotizing soft tissue infections have been recently studied. Brothers et al10 found magnetic resonance imaging to be extremely accurate in predicting necrosis and the need for operation in patients with fasciitis.Majeski and Majeski 11 reported a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside. While both these methods were shown reliable, the question remains whether they allow for the rapid diagnosis required in cases of necrotizing fasciitis.
Streptococcal toxic shock syndrome caused by group A streptococcus was first reported in 1987.12 In 1989, Stevens et al6 reported a case series of 20 patients from the Rocky Mountain region with group A streptococcal infection remarkable for the severity of local tissue destruction and life-threatening systemic toxicity. The mortality rate of the series was 30%. In 1993, the Working Group on Severe Streptococcal Infections set out a consensus definition for group A streptococcal toxic shock syndrome.13
Hypotension and the isolation of group A streptococcus from a normally sterile site (blood and soft tissues) were the features of our patient’s presentation included in the criteria for diagnosis of streptococcal toxic shock syndrome. She did not, however, have an elevated creatinine (although her urine output was remarkably low), coagulopathy, liver involvement, adult respiratory distress syndrome, or evidence of soft tissue necrosis; therefore, the diagnoses of streptococcal toxic shock syndrome or necrotizing fasciitis could not be made. We, however, found that without prompt treatment, the patient would have decompensated further and that criteria for streptococcal toxic shock syndrome would have ultimately been met.
The 3 main objectives in the treatment of septic shock are restoration of tissue perfusion, prompt antimicrobial therapy, and removal of the source of infection. In our case, removal of the offending source necessitated debridement of all potentially infected or devitalized soft tissue. Prompt and aggressive exploration and debridement is essential to limit complications and prevent extension of the infection into adjacent areas. Bilton et al14 compared mortality in patients with necrotizing fasciitis based on adequacy of surgical care. Aggressive debridement in this study was defined as “wide surgical debridement at initial recognition of the disease process.” Patients who underwent aggressive surgical debridement from the outset had a mortality rate of 4.2% versus 38.0% for patients who received delayed care or inadequate preliminary therapy.
Filbin et al15 described a case similar to that of our patient in which a 25-year-old man presented with 2 days of upper extremity erythema associated with septic shock. The patient also lacked crepitation on examination and radiographs were unremarkable for subcutaneous air. The patient was aggressively resuscitated and brought to the operating room for irrigation and debridement. However this patient had evidence of end-organ damage and a pathologic examination revealed presence of fascial necrosis. This case, in addition to the one presented in this report, underscores the difficulty in distinguishing aggressive cellulitis from necrotizing fasciitis.
Although surgery is not often considered for patients with cellulitis, our patient benefited from surgical intervention and soft tissue decompression although she did not meet diagnostic criteria for toxic shock syndrome or necrotizing fasciitis. In cases of necrotizing fasciitis as well as rapidly progressive cellulitis, prompt diagnosis and aggressive treatment may help patients avoid the catastrophic consequences of rapidly progressive group A streptococcal infections.
- Hribalova V. Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med. 1988; 108(5):772.
- Lamagni TL, Darenberg J, Luca-Harari B, et al. Epidemiology of severe Streptococcus pyogenes disease in Europe. J Clin Microbiol. 2008; 46(7):2359-2367.
- Stevens DL. Streptococcal toxic-shock syndrome: spectrum of disease, pathogenesis, and new concepts in treatment. Emerg Infect Dis. 1995; 1(3):69-78.
- O’Loughlin RE, Roberson A, Cieslak PR, et al. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004. Clin Infect Dis. 2007; 45(7):853-862.
- Hsiao GH, Chang CH, Hsiao CW, Fanchiang JH, Jee SH. Necrotizing soft tissue infections. Surgical or conservative treatment? Dermatol Surg. 1998; 24(2):243-247; discussion 247-248.
- Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989; 321(1):1-7.
- Dupuy A, Benchikhi H, Roujeau JC, et al. Risk factors for erysipelas of the leg (cellulitis): case-control study. BMJ. 1999; 318(7198):1591-1594.
- Carratala J, Roson B, Fernandez-Sabe N, et al. Factors associated with complications and mortality in adult patients hospitalized for infectious cellulitis. Eur J Clin Microbiol Infect Dis. 2003; 22(3):151-157.
- Callahan TE, Schecter WP, Horn JK. Necrotizing soft tissue infection masquerading as cutaneous abcess following illicit drug injection. Arch Surg. 1998; 133(8):812-817; discussion 817-819.
- Brothers TE, Tagge DU, Stutley JE, Conway WF, Del Schutte H Jr, Byrne TK. Magnetic resonance imaging differentiates between necrotizing and non-necrotizing fasciitis of the lower extremity. J Am Coll Surg. 1998; 187(4):416-421.
- Majeski J, Majeski E. Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. South Med J. 1997; 90(11):1065-1068.
- Cone LA, Woodard DR, Schlievert PM, Tomory GS. Clinical and bacteriologic observations of a toxic shock-like syndrome due to Streptococcus pyogenes. N Engl J Med. 1987; 317(3):146-149.
- Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections. JAMA. 1993; 269(3):390-391.
- Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg. 1998; 64(5):397-400; discussion 400-401.
- Filbin MR, Ring DC, Wessels MR, Avery LL, Kradin RL. Case records of the Massachusetts General Hospital. Case 2-2009. A 25-year-old man with pain and swelling of the right hand and hypotension. N Engl J Med. 2009; 360(3):281-290.
Mr Bharucha and Drs Alaia, Paksima, Christoforou, and Gupta are from the Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York.
Mr Bharucha and Drs Alaia, Paksima, Christoforou, and Gupta have no relevant financial relationships to disclose.
Correspondence should be addressed to: Neil J. Bharucha, BA, 415 E 37th St Apt 31D, New York, NY 10016 (firstname.lastname@example.org).