Fasciitis and Streptococcal Toxic-shock Syndrome: The Importance of Early Diagnosis and Surgical Management

Abstract

Introduction: Fasciitis of the limb and toxic-shock syndrome due to Streptococcus Pyogenes infection is considered a surgical emergency. This condition may occur in previously healthy patients. It is a life-threatening condition with high morbidity rates when treatment is delayed due to poor diagnosis and non-surgical intervention.

Case report: 17-year-old male patient sustained a minor ankle trauma while skating. Initials findings were a 1cm wound in relation with his left lateral malleolus and moderate swelling. About 6 h later, the patient was admitted at the emergency room with disproportionate limb pain, increased swelling, persistent fever, paleness, tachycardia, and hypotension. The patient was intubated due to his unstable hemodynamic condition and underwent fasciotomy of the limb. A vacuum-assisted closure device was used. After the first surgical procedure, patient's condition radically improved. He was extubated with good clinical prognosis. He underwent several surgical procedures in a 3-weeks lapse until the wound finally healed.

Conclusion: Streptococcal toxic-shock syndrome and limb fasciitis have no specific early signs or symptoms. It seems that clinical dissociation (disproportionate pain together with a minor wound) should become an alarm sign to trauma surgeons. It is important to contemplate this serious condition as differential diagnosis in every patient undergoing trauma with torpid evolution. Aggressive surgical management is the gold standard treatment and should not be delayed.

Keywords: Case report; lower limb fasciitis; streptococcal toxic-shock syndrome.

Figure 1

(a) Lateral malleolus wound. (b) Limb edema without skin necrosis.

Figure 2

(a, b, c) Diffuse edema with infrapatellarinterfascial collection.

Figure 3

(a and b) Mubarak’s double fasciotomy.

Figure 4

(a) Primary closure. (b) Edema is gone.