Gastric Gangrene Due to Acute Necrotizing Gastritis Secondary to Group A Streptococcus Bacteremia

Abstract

Introduction: Acute necrotizing gastritis, a variant of phlegmonous gastritis is an extremely rare cause of gastric necrosis where major gastric vessels remain patent yet gastric gangrene occurs secondary to a necrobiotic infection. We present such a case secondary to Group A Streptococcal infection. Case Presentation: A 73 year-old-female with a history of polymyalgia rheumatica on chronic prednisone presents with one day history of retrosternal chest pain radiating to the back with associated nausea and non-bloody emesis. There was an antecedent two week history of sore throat with a severe post-nasal drip. On presentation, the patient was toxic appearing with features of septic shock. Cross sectional imaging reveals marked gastric wall thickening with patent gastric vasculature. Upper endoscopy defines areas of gastric ischemia with necrotic ulcerations on the lesser curvature (Figure 1). Exploratory laparotomy with distal gastrectomy demonstrates acute necrotizing gastritis with gastric wall gangrene; histopathology reveals numerous gram-positive cocci in chains (Figure 2, 3). Blood cultures were positive for Group A Streptococcus. There was no evidence of an underlying hypercoagulable or rheumatological disorder; an extensive infectious disease evaluation inclusive of TEE, CT chest and sinus, bronchoscopy, and thoracentesis was negative. The patient was successfully treated with penicillin.Figure 1Figure 2Figure 3Conclusion: This case highlights an atypical presentation of Group A Streptococcal pharyngitis with consequent gastric gangrene. There is scant literature regarding acute nectrotizing gastritis secondary to an inciting infectious etiology. Early recognition remains the cornerstone in mitigating against significant morbidity and mortality.