EV0373
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Clinical ID: community-acquired infections including CAP, sepsis, STD, ...
Digital artery thrombosis and digital necrosis secondary to group A streptococcal cellulitis
D. Harrington1, D. Moore2
1University College Hospital London, London, United Kingdom
2University College Hospital, London, United Kingdom
INTRODUCTION:
We report the case of a young female presenting with group A streptococcal cellulitis of the index finger complicated by digital
ischaemia and necrosis.
CASE REPORT:
A 30 year old woman presented with a one day history of a hot, red, and swollen right index finger. She reported a similar episode
twelve months previously involving the left 4th finger, confirmed to be group A streptococcal cellulitis which required two surgical
debridements.
On examination she was febrile (38ºC) and tachycardic (pulse 120 beats per minute), with a normal blood pressure. The right index
finger and dorsal hand was hot, swollen and erythematous consistent with cellulitis. CRP was 101mg/L and WCC 10.22 x10^9/L. Hand Xray was normal. Following review by the hand surgical team she was treated for hand cellulitis with high-dose intravenous flucloxacillin and
benzylpenicillin, and elevation.
Within 24 hours of admission the finger had become dusky blue and non-blanching distal to the proximal interphalangeal joint (PIPJ);
this was non-painful.
She was commenced on aspirin, treatment dose dalteparin, and topical GTN. Streptococcus pyogenes sensitive to erythromycin
and penicillin G was isolated both from wound culture and blood culture. Flucloxacillin was replaced by high-dose intravenous clindamycin
and benzylpenicillin was continued
Proximally the cellulitis began to improve over the next 3 days but the distal finger remained blue. Inflammatory markers improved.
She was taken to theatre, which revealed no blood flow of the deeper tissues distal to the PIPJ, no pus, and no involvement of the flexor
tendon sheath. The cellulitis continued to improve, although the finger became black and necrotic distal to the PIPJ. She was discharged to
outpatient care after completing 10 days of antibiotics, for subsequent outpatient amputation.
DISCUSSION:
We present the case of a rapid onset, aggressive cellulitis of the finger which resulted in presumed digital artery thrombosis within
24 hours of onset. Group A streptococcus is a common cause of severe soft tissue infections. Digital artery thrombosis is an extremely rare
complication of group A streptococcal cellulitis. This case is remarkable for the history 12 months earlier of a similar group A streptococcal
cellulitis in her left 4th finger, also requiring debridement.
Group A streptococcal infections are common, and are increasing in incidence and virulence. This increasing virulence is likely due
to the increasing prevalence of exotoxin-producing serotypes.
Reports of digital necrosis secondary to Group A streptococcal infections were common in the pre-penicillin era, however reports
are now exceedingly rare.
Treatment in these cases requires high dose, targeted antibiotics, anticoagulation, elevation of the affected limb, and early surgical
assessment. Alternative causes of thrombosis need to be considered and excluded.