Necrotizing Fasciitis and Fatal Septic Shock Associated with Streptococcus constellatus

Abstract

Abstract Introduction/Objective Streptococcus anginosus group consists of three species: S. anginosus, S. intermedius, and S. constellatus (SC), normal flora in the human oral cavity, gastrointestinal and urogenital tracts. What makes them unique is their ability to form abscesses. Methods/Case Report We report a case of a 43 year old morbidly obese bipolar male presenting with general malaise and diarrhea. He had a history of uncontrolled diabetes mellitus Type 2 and persistent right thigh wound. Admitting labs revealed diabetic ketoacidosis. Physical examination revealed a right medial thigh ulcer with necrotic scrotal skin, after which he underwent urgent surgical debridement. Wound culture grew SC. Debrided tissue measured 44 x 17 x 4 cm. Histology revealed abscesses next to zones of pale gray necrotic tissue having a granular appearance without associated neutrophils. Gram stain of these pale gray zones revealed sheets of Gram positive cocci, consistent with Stage III necrotizing fasciitis (NF), which has 47% mortality. He died shortly after surgery with death attributed to septic shock. Toxic shock syndrome is most often associated with Group A Streptococcus. However, other rare pathogenic streptococci, including SC, may be associated with a similar syndrome. Gram stain is essential in confirming NF, characterized by pale gray necrosis with a granular appearance. Results (if a Case Study enter NA) NA Conclusion Our case highlights the risk of fatal NF due to SC. Identification of SC in a deep wound warrants early surgical intervention for adequate source control and administration of appropriate antibiotic. Poor diabetic control and ulcerated chronic thigh wound predisposed our patient to fatal necrotizing fasciitis due to SC, confirmed by Gram stain.