Case Presentation: A 55-year-old man with a past medical history of poorly controlled diabetes and remote intravenous drug use was evaluated for a right chest wall infection. 1 week prior to presentation, he had chest wall erythema, pain resulting in decreased range of motion, fevers, chills, decreased appetite, and weight loss. He presented to an outside hospital where a CT performed showed right chest wall swelling and edema, but no fluid collection. Ceftriaxone led to initial improvement, but due to persistent pain and leukocytosis, he was transferred to our hospital for consideration of surgical debridement. Upon transfer, he remained stable on antibiotics, and the surgical service requested transfer to medicine for ongoing antibiotic management without operative plans. Within 12 hours, the patient’s clinical status deteriorated with uncontrolled pain. On exam, his vitals were unremarkable, but the swelling had rapidly expanded across his right chest with the right pectoralis muscle becoming rigid and untouchable due to pain. Both surgery and radiology were emergently called, and antibiotics were expanded to ertapenem, vancomycin, and clindamycin for presumed necrotizing fasciitis. Emergent CT showed a large fluid and gas collection measuring 4.0 x 12.5 x 12.3 cm in the right anterior chest wall deep to the pectoralis muscle with invasion through the 2nd and 3rd ribs (Figure 1). The patient was immediately taken to the operating room for debridement. 400cc of pus was found deep to the pectoralis and drained; fractured ribs were removed. Operative cultures grew Streptococcus agalactiae and antibiotics were transitioned to 4 weeks of IV ceftriaxone and then 4 weeks of Augmentin. Formal diagnosis was deep soft tissue necrotizing infection secondary to Streptococcus agalactiae with associated osteomyelitis.
Discussion: Necrotizing soft tissue infections (NSTIs) are bacterial infections that cause tissue destruction and can confer up to a 35% mortality rate, especially when presenting with septic shock or toxic shock syndrome(1,5). They can be misdiagnosed due to their similar presentation to cellulitis and routine abscesses(1). Risk factors for development include diabetes, obesity, IV drug use, and immunosuppression(3). NSTIs are divided between polymicrobial (Type 1) and monomicrobial (Type 2) infections. The most common pathogens are Streptococcus pyogenes (Group A streptococcus), Staphylococcus aureus, and Clostridium spp., so initial antimicrobial therapy needs to be broad(5). In this case, Group B Streptococcus, which is rarely observed to cause NSTIs in the literature(6-8), was the causative organism. It presents similarly to Group A Streptococcus infections and possesses similar risk factors. Delayed diagnosis and intervention in retrospective data is associated with poorer outcomes(2,4). Conversely, early recognition and referral for surgical debridement within 12 hours of presentation has been shown to have improved mortality outcomes(2,4).
Conclusions: This case demonstrates that hospitalists must be vigilant in recognizing surgical emergencies and considering NSTIs, even if patient symptoms initially appear mild. This patient developed rapid progression of pain after transfer to the medical service. Due to the culture of collaboration and high clinical suspicion, the surgical, medical, and radiological teams were able to rapidly communicate, discuss, and expedite the patient’s care which ultimately led to a good patient outcome.
