Fulminant group B Streptococcal necrotizing fasciitis in a p
Group A Streptococcus is well established as the most common pathogen causing necrotizing fasciitis. In contrast, Group B Streptococcus (GBS, or Streptococcus agalactiae) is a rare cause of necrotizing fasciitis, particularly in adults. We present the case of a patient who developed a fulminant case of GBS necrotizing fasciitis on a backdrop of a previously undiagnosed malignancy, and review the relevant literature.

A 70 year old woman—a visiting tourist from Canada with no known medical problems--was brought to an emergency room on Maui with confusion and severe pain in her upper back.

The patient was a retiree without known medical problems; three days prior to admission, during a vacation on Maui, she developed pain in the region of her right scapula without antecedent trauma. She sought relief from a chiropractor and masseuse but her back pain grew constant and severe, she became confused, and her speech grew slurred; her family brought her to the emergency room for evaluation.

On presentation the patient was febrile (102.9 F), tachycardic, tachypneic, hypotensive, and disoriented. Her physical exam showed erythema, evolving subcutaneous ecchymoses, and extreme tenderness in her right upper back, shoulder area, and right upper arm.

The patient’s labs were remarkable for a peripheral white blood cell count of 13.5 K/uL with 100% lymphocytes (absolute neutropenia). The patient’s hemoglobin was 10.7 g/dl; her platelet count and creatinine were normal, as was her Hemoglobin A1c (5.3%).

The patient was started empirically on Vancomycin and Piperacillin-Tazobactam for a presumed soft tissue infection with sepsis, and General Surgery was consulted. A thoracic CT scan showed body wall anasarca without gas in the soft tissues or musculature of her back, as well as extensive thoracic adenopathy concerning for possible lymphoma or metastatic malignancy.

Profound hypotension ensued, requiring intubation and pressor support; the patient was taken to the OR emergently. Intra-operatively, necrotizing fasciitis involving her deep dermis and multiple muscle groups was found, requiring extensive debridement and resection of much of the skin, adipose tissue, and fascia of her upper back (Fig. 1). Enlarged lymph nodes near her scapula were sent for pathology. Tissue Gram stain from the OR showed many gram-positive cocci in pairs and chains. Her antibiotics were changed to Ceftriaxone and high-dose Clindamycin for Streptococcal necrotizing fasciitis, and a three-day course of intravenous immunoglobulin was begun.

Floridly septic, the patient was taken back to the OR the following day for further debridement, and her extensive wounds were left open (Fig. 2); she stabilized subsequently. GCSF was started and antibiotics were continued. Tissue cultures from the OR and blood cultures from admission both grew Group B streptococccus (Streptococcus agalactiae) in pure culture, sensitive to Penicillin (MIC 0.12 μg per milliliter).

Lymph nodes from the patient’s back showed architectural effacement by a population of small, mature lymphocytes; immunohistochemistry was consistent with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (Fig. 3). Flow cytometry was positive for a mature B-cell lymphoproliferative disorder.

The patient slowly recovered with intensive ICU support. She was weaned off vasopressors and extubated within a week of admission; Clindamycin was stopped after six days of treatment, and Ceftriaxone continued.

Nine days after admission she was transferred by air ambulance to a hospital in Vancouver to be nearer her family. Ceftriaxone was stopped after fourteen days of total therapy. She underwent extensive skin grafting, and is receiving treatment for her CLL/lymphocytic lymphoma currently.

Learning Points:
1. Group B Streptococcus rarely causes necrotizing fasciitis in immunocompetent adults.
2. Invasive group B Streptococcal infections may be increasing in non-pregnant adults.

Source: https://www.sciencedirect.com/science/article/pii/S221425091930294X
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