Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Necrotizing Fasciitis of the Labia Caused by Beta Hemolytic Streptococcus and Streptococcus anginosus Zach Bowens, OMS-III 1 ; Hannah Flynn, OMS-III 1 ; Jordan Winebrenner, OMS-III 1 ; Michaeleena Carr, DO. 2; Lindsay Tjiattas-Saleski, DO, MBA, FACOEP, FACOFP 1 . ​ Edward Via College of Osteopathic Medicine- Carolinas Campus, Spartanburg, SC.​ 1 PRISMA Health Tuomey, Sumter, SC. 2 Abstract Work Up & Treatment

Discussion

Necrotizing fasciitis (NF) is commonly associated with immunosuppression, diabetes mellitus (DM), and traumatic injuries; however, DM has been put forward as one of the most common predisposing factors, being present in up to 43.9% of NF cases 11-13 . NF is more prevalent in cases of uncontrolled DM 9-10 . Our patient had an elevated blood glucose 329 (64 to 100 mg/dL) and diabetic foot ulcers. This suggests that her diabetes had been chronically unmanaged, putting her at greater risk for developing NF. ​ It is suggested that the rapid course of NF Type 1 is due to polymicrobial synergism 14 . This patient’s culture biopsy was positive for Beta Hemolytic Streptococcus and Streptococcus anginosus. Streptococcus anginosus has been shown to exhibit synergistic activity with Edwardsiella tarda; however, it has not been seen with Beta Hemolytic GBS 14 . This novel synergistic relationship demonstrates the multifaceted nature of NF and a new area for future study. Both Beta Hemolytic Streptococcus and Streptococcus anginosus are gram positive cocci; therefor, they are sufficiently covered by empiric antimicrobial treatment. ​ Delay in diagnosis and treatment of NF has been show to increase mortality by up to 35%, making it the largest contributor to increased mortality from NF 15-17 . This delay may be due to the similarity of the early stages of NF and cellulitis, abscesses, etc. There are currently no guidelines for the early diagnosis of NF. Therefore, the diagnosis is dependent upon manifestations of infection that occur late in the disease course and a high index suspicion. The diagnosis of NF and administrations of broad-spectrum antibiotics usually occurs in the late stages of the disease process 18 . Additionally, treatment of NF with antibiotics alone, without surgical debridement, is associated with a nearly 100% mortality rate, highlighting the need for early diagnosis as well 19 . Delayed diagnosis allows for the development of significant sequelae that can be exacerbated by comorbidities such as diabetes mellitus and immunocompromised states. At present, the recommendations for early recognition, diagnosis, and treatment of NF are for healthcare professionals to maintain a high index of suspicion and develop an understanding of the various manifestations of NF 20 . ​ The delay in diagnosis of NF contributes to the morbidity and mortality of the disease course. There is no indication that the patient presented in this work sought medical care in the early stages of the disease process. It may be that the patient did not recognize the severe nature of her condition early in the disease process. This combined with its rapid course may explain the advanced presentation. ​ Taken together, this work demonstrates the need for guidelines concerning the early diagnosis biopsy, culture, and surgical debridement of NF.​

Work Up: The laboratory results revealed a urinary tract infection, with a urine culture >100,000 CFU, WBC (UA) 5-10, and Bacteria (UA) 3+ with trace leukocytes, nitrites, blood, and protein 100 (0-14 mg/dL). Additionally, urine glucose (≥ 2000) and ketones (40) were elevated. The patient’s pregnancy test was negative, and the BMP showed low sodium 134 (136 to 144 mmol/L) and low CO2 19 (23 to 29 mmol/L) and elevated blood glucose 329 (64 to 100 mg/dL). The patient’s CBC with differential revealed microcytic anemia with a MCV of 74.1% (79.0 - 92.2 fL), WBC 16 (4.3-9.1 103mm3), RBC 3.48 (4.63 - 6.08 106mm3), Hemoglobin 7.6 (13.7 - 17.5 g/dL), and Hematocrit 25.8 (40.1 - 51.0 %). The CT scan showed gas within the soft tissue of the right labia and glute with soft tissue thickening and fat stranding without fluid collection (figure 1.). Treatment: The patient was started on clindamycin (900 mg), vancomycin load dose, and piperacillin and tazobactam (3.375 gm). The patient was then taken to surgery for debridement and biopsy. Debridement revealed a large amount of subcutaneous gas in the perianal and right labial regions and the biopsy culture grew Beta Hemolytic Streptococcus and Streptococcus anginosus.

Necrotizing Fasciitis (NF) can present similarly to routine cutaneous skin infections such as cellulitis and is generally misdiagnosed in its early stages. This contributes to its rapid progression and subsequent morbidity and mortality. This case presents a female patient with NF of the right labia and buttock, that was caused by Beta Hemolytic Streptococcus and Streptococcus anginosus, demonstrating a rare cause of polymicrobial NF. Her significant comorbidities and late recognition of the disease process contributed to the progression of severe disease within two days of symptom onset. There are currently no guidelines on early recognition of NF. Largely, the guidelines relate to the treatment and care of those in the late stages of the disease process. This case report has two aims: 1) present a rare etiology of polymicrobial NF and 2) highlight the need for guidelines and protocols for the early recognition, diagnosis, and treatment of NF.​ Necrotizing Fasciitis (NF) is a rare but serious soft tissue infection that can progress rapidly if not promptly diagnosed and treated with broad-spectrum antibiotics and surgical debridement. 1 The incidence of NF ranges between 0.18-1.55 per 100,000 persons. Since the early 2000s, the mortality rate of NF has fallen and remained steady at 20%, which is between 0-0.3 per 100,000 persons. 2 Additionally, predisposing factors, such as advanced age, prolonged hospital stays and female sex, though it affects both men and women equally, have been seen to have a more severe course. 3-6 Idiopathic NF tends to occur more often in the perianal region in those with poor hygiene due to a combination of the native microbial environment and favorable routs to spread such as intersecting fascial planes. 7-10 NF is generally separated into two categories: ​​ NF Type 1 : due to infections by a combination of gram-negative and gram-positive aerobic and anaerobic bacteria. It is associated with immunocompromised states, diabetes, and mucosal breaches, often due to surgical interventions. ​​ NF Type 2 : due to infection by gram-positive cocci such as Staphylococcus and Streptococci strains and is generally caused by minor penetrating traumas and breaches in the skin. 6 Introduction The patient was a 33-year-old African American female who presented to the emergency department with generalized body aches and a right sided labial abscess that had worsened over the past few days. She denied vomiting and upper respiratory infection symptoms. Upon presentation, she was fatigued, but well developed, well nourished, alert, and oriented (X3) with a blood pressure of 180/92 (left arm sitting), pulse of 105 bpm, temperature of 98 Σ F/ 36.7 Σ C, respiratory rate of 19 bpm, weight of 118 kg (260 lbs ), SpO2 of 100%, and a BMI of 39.53 kg/m². ​ The patient’s past medical history was notable for morbid obesity, hypertension, diabetes mellitus, diabetic foot ulcers, and Iron deficiency anemia. Medications include metformin, lisinopril, and famotidine. The patient’s physical exam was normal except that she was obese and that her right labia and right posterior lateral perineum were indurated and erythematous. The right labia was also tender to palpation, and there was no opening or drainage. This was the patients’ first perianal pathology on record.​ Case Presentation

Findings

Acknowledgements

Lindsay Tjiattas-Saleski, DO., Michaeleena Carr, DO., Noel Brownlee, MD. Edward Via College of Osteopathic Medicine- Carolinas Campus.​

Figure 1.

References

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2024 Research Recognition Day