Group G streptococcal necrotizing soft tissue infection

We report a rare case of streptococcal necrotizing soft tissue infection in the lower leg caused by Group G Streptococcus infection. A 61-year-old female had idiopathic lymph edema of the left leg. She complained of swelling and burning of the leg after pharyngitis and flulike symptoms with high fever. Laboratory examinations showed elevated white blood cells (11110/μl), creatine phosphokinase (1781 U/l), and C-reactive protein (CRP; 25.86 mg/dl). Magnetic resonance imaging (MRI) T1-weighted imaging showed a high-intensity area in the muscle, suggesting muscle necrosis with hemorrhage. MRI T2-weighted imaging also showed the presence of a high-intensity area in subcutaneous tissue and superficial fascia. Over a few hours, redness and purpura of the left leg progressed rapidly. We performed a fasciectomy and debridement 7 hours after admission. At the fasciectomy, the subcutaneous tissue, superficial fascia and muscle appeared necrotic with a large amount of translucent fluid. Considering the findings that (1) group G Streptococcus was isolated from blood cultures, (2) a blood coagulation test suggested disseminated intravascularcoagulation, and (3) deep soft tissue infection ornecrotizing fasciitis was observed, we diagnosed a toxic shock-like syndrome. She was treated with penicillin, clindamycin, and meropenem antibiotics in combination with intravenous immunoglobulin administration. Because this treatment was insufficient to improve the elevated CRP, we again performed MRI analysis to evaluate whether other areas of necrotic tissue remained in the leg. MRI T1-weighted imaging still showed the presence of a high-intensity area in the gastrocnemius, suggesting that the streptococcal infection had resulted in necrosis of the muscle. We performed debridement of the necrotic gastrocnemius and tibialis anterior muscles, which successfully improved her general condition and laboratory data. Subsequently, she underwent split-skin grafting and was discharged.