A 60‐year‐old white woman with a history of sarcoidosis (remote and in remission), asthma, chronic obstructive pulmonary disease (COPD), and emphysema presented to the emergency department with a 1‐week history of worsening dyspnea, productive cough, fatigue, and a 3‐day history of left‐hand edema. She denied fever, chills, or recent trauma. The patient was a non‐smoker and never received the pneumococcal vaccine. Her home medications included albuterol and fluticasone propionate/salmeterol xinafoate. Vital signs were temperature 98.8°F, pulse 111 beats/minute, respirations 24 per minute, blood pressure 132/62 mmHg, and oxygen saturations 90% on 3 L of oxygen via nasal cannula. She was lethargic with peripheral cyanosis, had accessory muscle use, bilateral rhonchi, and a markedly edematous left hand. Significant laboratory studies included metabolic acidosis on arterial blood gas, WBC 29.1 × 109/L with 55% bands, BUN 57 mg/dL, and creatinine 2.59 mg/dL. She was started on ceftriaxone and azithromycin and required intubation in the ED. A computed tomographic scan showed right upper and middle lobe necrotizing pneumonia. By hospital day 2 her entire left arm was edematous with extensive blistering and necrosis. Excision of nonviable tissue was emergently performed in the OR. S. pneumoniae was identified in the blood and wound cultures and found to be sensitive to penicillin. On hospital day 5 the patient sustained cardiac arrest and died. An inspection of the culture plate identified mucoid‐app earing colonies of S. pneumoniae suggestive of a more invasive serotype.
Necrotizing fasciitis (NF) is a soft‐tissue infection that can carry high morbidity and mortality. S. pneumoniae is a rare cause of NF. There have been 10 other cases reported describing NF in adults with S. pneumoniae; however, the patients in each of these cases had antecedent trauma or an underlying immunosuppressive comorbidity. To our knowledge this is the first case reported in the literature of NF with S. pneumoniae found to be the causative agent in an adult patient without clear underlying immunocompromise, comorbidity, or trauma. Invasive serotypes of S. pneumoniae make up some of the subunits for the pneumococcal vaccines that are available. Our patient was an appropriate candidate for the PPV23 vaccine. The vaccine may have prevented the magnitude of her invasive pneumococcal disease.
This case demonstrates the importance of health care provider awareness of invasive mucoid strains of S. pneumoniae. We advocate careful screening of patients and the use of the pneumococcal vaccine.
K. Lebak, none; D. Schiller, none; S. Sandal, none; P. Yodice, none; A. Houng, none; M. Youssef‐Bessler, none.