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      Necrotizing fasciitis and fatal septic shock associated with Streptococcus constellatus

      case-report
      Author(s): 1 , 2 , , 1
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Autopsy & Case Reports
      Publisher: Hospital Universitário da Universidade de São Paulo
      Keywords: Bacteremia, Debridement, Diabetic Ketoacidosis, Skin Ulcer, Streptococcus anginosus

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          ABSTRACT

          Streptococcus constellatus is usually a benign, commensal bacteria but has increased incidence in blood cultures and abscesses. This pathogenic involvement is most prevalent in individuals with underlying medical conditions, such as solid tumors and type 2 diabetes mellitus, as well as in cases of community-acquired infections. We report a 43-year-old male with a right medial thigh ulcer and necrotic scrotal skin. The wound culture from surgical debridement grew Streptococcus constellatus, and histology was consistent with stage III necrotizing fasciitis. Regardless of etiology, the mortality rate of patients with necrotizing fasciitis is greatly decreased with early intervention and thorough surgical debridement.

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          Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality.

          Chin J. Wong, Eric Tan, Lay Khin … (2003)
          Necrotizing fasciitis is a life-threatening soft-tissue infection primarily involving the superficial fascia. The present report describes the clinical presentation and microbiological characteristics of this condition as well as the determinants of mortality associated with this uncommon surgical emergency. The medical records of eighty-nine consecutive patients who had been admitted to our institution for necrotizing fasciitis from January 1997 to August 2002 were reviewed retrospectively. The paucity of cutaneous findings early in the course of the disease makes the diagnosis difficult, and only thirteen of the eighty-nine patients had a diagnosis of necrotizing fasciitis at the time of admission. Preadmission treatment with antibiotics modified the initial clinical picture and often masked the severity of the underlying infection. Polymicrobial synergistic infection was the most common cause (forty-eight patients; 53.9%), with streptococci and enterobacteriaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus (sixty-three patients; 70.8%). Advanced age, two or more associated comorbidities, and a delay in surgery of more than twenty-four hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of more than twenty-four hours was correlated with increased mortality (p < 0.05; relative risk = 9.4). Early operative débridement was demonstrated to reduce mortality among patients with this condition. A high index of suspicion is important in view of the paucity of specific cutaneous findings early in the course of the disease.
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            The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.

            Chin-Ho Wong, Lay-Wai Khin, Kien-Seng Heng … (2004)
            Early operative debridement is a major determinant of outcome in necrotizing fasciitis. However, early recognition is difficult clinically. We aimed to develop a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections: the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. Retrospective observational study of patients divided into a developmental cohort (n = 314) and validation cohort (n = 140) Two teaching tertiary care hospitals. One hundred forty-five patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses admitted to the participating hospitals. None. The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis. Control patients (n = 225) were randomly selected from patients admitted with severe cellulitis or abscesses during the same period. Hematologic and biochemical results done on admission were converted into categorical variables for analysis. Univariate and multivariate logistic regression was used to select significant predictors. Total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein were selected. The LRINEC score was constructed by converting into integer the regression coefficients of independently predictive factors in the multiple logistic regression model for diagnosing necrotizing fasciitis. The cutoff value for the LRINEC score was 6 points with a positive predictive value of 92.0% and negative predictive value of 96.0%. Model performance was very good (Hosmer-Lemeshow statistic, p =.910); area under the receiver operating characteristic curve was 0.980 and 0.976 in the developmental and validation cohorts, respectively. The LRINEC score is a robust score capable of detecting even clinically early cases of necrotizing fasciitis. The variables used are routinely measured to assess severe soft tissue infections. Patients with a LRINEC score of > or = 6 should be carefully evaluated for the presence of necrotizing fasciitis.
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              Determinants of mortality for necrotizing soft-tissue infections.

              Allison R. McHenry, Wojciech J. Piotrowski, D Petrinic … (1995)
              The authors determined the risk factors of mortality in patients with necrotizing soft-tissue infections (NSTIs) and examined the incidence and mortality from NSTI secondary to Streptococcus pyogenes. All patients with NSTIs who were treated between January 1989 and June 1994 were analyzed for presentation, etiology, factors important in pathogenesis and treatment, and mortality. Sixty-five patients were identified with NSTIs secondary to postoperative wound complications (18), trauma (15), cutaneous disease (15), idiopathic causes (10), perirectal abscesses (3), strangulated hernias (2), and subcutaneous injections (2). Necrotizing soft-tissue infections were polymicrobial in 45 patients (69%). S. pyogenes was isolated in only 17% of the NSTIs, but accounted for 53% of monomicrobial infections. Eight of ten idiopathic infections were caused by a single bacterium (p = 0.0005), whereas 82% of postoperative infections were polymicrobial. An average of 3.3 operative debridements per patient and amputation in 12 patients were necessary to control infection. The overall mortality was 29%; mortality from S. pyogenes infection was only 18%. The average time from admission to operation was 90 hours in nonsurvivors versus 25 hours in survivors (p = 0.0002). Other risk factors previously associated with the development of NSTIs did not affect mortality. Early debridement of NSTI was associated with a significant decrease in mortality. S. pyogenes infection was the most common cause of monomicrobial NSTI, but was not associated with an increased mortality.
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                Author and article information

                Contributors
                Fareed Rajack:
                ORCID: http://orcid.org/0000-0002-0302-6228
                Role: collecting the data and figures and drafting the manuscript
                Shawn Medford:
                ORCID: http://orcid.org/0000-0001-6145-3036
                Role: drafting the manuscript and preparing the case report for submission
                Tammey Naab:
                ORCID: http://orcid.org/0000-0003-0710-4809
                Role: editing and overseeing the preparation of the case report submission
                Journal
                Journal ID (nlm-ta): Autops Case Rep
                Journal ID (iso-abbrev): Autops Case Rep
                Journal ID (publisher-id): acrep
                Title: Autopsy & Case Reports
                Publisher: Hospital Universitário da Universidade de São Paulo
                ISSN (Electronic): 2236-1960
                Publication date (Electronic, pub): 08 January 2024
                Publication date (Electronic, collection): 2023
                Volume: 13
                Electronic Location Identifier: e2023467
                Affiliations
                [1 ] originalHoward University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
                [2 ] originalHoward University College of Medicine, Washington, D.C., United States of America
                Author notes

                Authors’ contributions: Fareed Rajack was responsible for collecting the data and figures and drafting the manuscript. Shawn Medford was responsible for drafting the manuscript and preparing the case report for submission. Tammey Naab was responsible for editing and overseeing the preparation of the case report submission.

                Conflict of interest: None.

                Correspondence Shawn Medford Howard University College of Medicine 520 W St NW, Washington, DC 20059, United States Phone: +1 (774) 218-3794 shawn.medford@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-0302-6228
                http://orcid.org/0000-0001-6145-3036
                http://orcid.org/0000-0003-0710-4809
                Article
                Publisher ID: acrep185123_EN Other ID: 00712
                DOI: 10.4322/acr.2023.467
                PMC ID: 10782520
                PubMed ID: 38213877
                SO-VID: 073ff89e-8a2c-404c-a9da-27b784e09f86
                Copyright © Copyright © 2023 The Author(s).
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 26 September 2023
                Date accepted : 14 December 2023
                Page count
                Figures: 2, Tables: 1, Equations: 0, References: 37
                Categories
                Subject: Clinical Case Report

                Keywords: bacteremia,debridement,diabetic ketoacidosis,skin ulcer,streptococcus anginosus
                Data availability:
                Keywords: bacteremia, debridement, diabetic ketoacidosis, skin ulcer, streptococcus anginosus

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