Correspondence

Necrotizing Fasciitis Due to Group A Streptococcus after an Accidental Needle-Stick Injury

N Engl J Med 1997; 337:1699December 4, 1997

Article

To the Editor:

While inserting a central venous catheter into a patient newly admitted to our hospital with sepsis of unknown cause, a healthy, 27-year-old resident was scratched on the dorsal aspect of her left fifth metacarpal–phalangeal joint by the needle used to insert the catheter. Within 14 hours, she noticed erythema, induration, and pain in her left hand. Shortly thereafter she had chills and fever (temperature, 38.4°C [101.1°F]), and nafcillin therapy was begun. Penicillin G and clindamycin were added when it became known that the patient the resident had treated died 12 hours after admission from group A streptococcus sepsis. During the ensuing 48 hours, leukocytosis developed in the resident, followed by leukopenia, a prolonged prothrombin time and partial-thromboplastin time, decreased hemoglobin level and platelet count, hypotension, and progression of the area of induration and erythema toward her elbow and axilla. On the basis of these findings, a diagnosis of necrotizing fasciitis due to group A streptococcus was made.

Surgical débridement of the region of cellulitis revealed necrosis of subcutaneous tissue, fascia, and muscle. Blood cultures obtained 1/2 hour after the initiation of antibiotic therapy and cultures of wound tissue obtained at the first surgical débridement, 32 hours after antibiotic therapy was begun, were sterile. As the patient improved, the wound defect was closed with a muscle flap, and she was discharged 17 days after admission.

In the only related published report we were able to find, cellulitis and a toxic shock–like syndrome developed in an emergency medical technician after exposure to respiratory tract secretions contaminated with group A streptococcus.1 Although the cultures of our patient's wound were sterile because the tissue was collected well after the initiation of antimicrobial therapy, the blood to which she was exposed was from a patient who had bacteremia with group A streptococcus at the time of the needle-stick injury. Group A streptococcus is a well-known cause of necrotizing fasciitis,2,3 and recent reports have emphasized the increase in aggressive infections due to this organism.3,4 Transmission of bacterial pathogens during blood-contaminated injuries is uncommon, presumably because of the relatively transient nature of most bacterial infections in the bloodstream, but this case demonstrates the potential for transmission. Even though the injury appeared minor, the infection progressed rapidly and required aggressive therapy. Invasive disease due to group A streptococcus is a potential hazard for those in the medical profession, especially those who perform invasive procedures.

Carin Hagberg, M.D.
Adriana Radulescu, M.D.
John H. Rex, M.D.
University of Texas–Houston Medical School, Houston, TX 77030

4 References

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   Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. N Engl J Med 1996;335:547-554
   Full Text | Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Jane A. Steer, Theresa Lamagni, Brendan Healy, Marina Morgan, Matthew Dryden, Bhargavi Rao, Shiranee Sriskandan, Robert George, Androulla Efstratiou, Fiona Baker, Alex Baker, Doreen Marsden, Elizabeth Murphy, Carole Fry, Neil Irvine, Rhona Hughes, Paul Wade, Rebecca Cordery, Amelia Cummins, Isabel Oliver, Mervi Jokinen, Jim McMenamin, Joe Kearney. (2011) Guidelines for prevention and control of group A streptococcal infection in acute healthcare and maternity settings in the UK. Journal of Infection
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2. 2

   M.S. Morgan. (2010) Diagnosis and management of necrotising fasciitis: a multiparametric approach. Journal of Hospital Infection 75:4, 249-257
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3. 3

   Takuma Tajiri, Genshu Tate, Tetsuji Enosawa, Hidetaka Akita, Nobuyuki Ohike, Atsuko Masunaga, Toshiaki Kunimura, Toshiyuki Mitsuya, Toshio Morohoshi. (2007) Clinicopathological findings in fulminant-type pneumococcal infection: Report of three autopsy cases. Pathology International 57:9, 606-612
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   GG Kihiczak, RA Schwartz, R Kapila. (2006) Necrotizing fasciitis: a deadly infection. Journal of the European Academy of Dermatology and Venereology 20:4, 365-369
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5. 5

   G. N. Rutty, A. Busuttil. (2000) Necrotizing Fasciitis. The American Journal of Forensic Medicine and Pathology 21:2, 151-154
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6. 6

   G Corti, A Bartoloni, C von Hunolstein, F Scopetti, M. I Buonomini, R Galligani, F Paradisi. (2000) Invasive Streptococcus pyogenes infection in a surgeon after an occupational exposure. Clinical Microbiology and Infection 6:3, 170-171
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