Rare presentation of necrotising fasciitis and streptococcal toxic shock syndrome by group A streptococcus.

Saeed S, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-222041 Description A 44-year-old healthy male presented to the emergency room with a 6-day history of right medial thigh pain and itching. Examination revealed mild erythema with superficial swelling, but no tenderness (figure 1A). Vital signs were stable. White cell count (WBC) was 11.2×10/L with no other significant laboratory abnormality. During the next 6 hours, his erythema and swelling extended to involve the whole thigh with the patient getting septic (spiking 102°F, heart rate 110/min and blood pressure 118/79 mm Hg). WBC trended up to 23×10/L and lactate 4.7 mmol/L. MRI was performed which showed possible myositis (figure 1B). Despite intravenous antibiotics (penicillin and vancomycin) and resuscitation, his clinical condition deteriorated rapidly. In the next 4 hours, patient was taken to the operative room for fasciotomy and exploration. Intraoperatively, patient was found to have fasciitis. Necrotic tissue was removed. Postoperative day 1, he developed a diffuse maculopapular rash and bullae involving right lower extremity (figure 1C). In the next 24 hours, his rash progressed to involve lower abdomen. He developed acute respiratory distress syndrome requiring intubation. Antibiotic regimen was switched to clindamycin/linezolid and the patient was taken to the operating room for a second look and further debridement. All the necrotic tissues were debrided. For the next couple of days, patient required multiple debridements (figure 2A). After his condition stabilised, his wound was closed by a skin graft (figure 2B,C). The wound culture was positive for Group A streptococcus pyogenes. Patient was discharged home with oral antibiotics. Toxic shock syndrome (TSS) is a rare fatal disease with mortality reaching as high as 70%. Most frequent cause of TSS is Gram-positive Rare presentation of necrotising fasciitis and streptococcal toxic shock syndrome by group A streptococcus