Research Article
Group a Streptococcus Necrotizing Soft Tissue Infection Secondary to Corticosteroid Injection: A Case Report and Literature Review
Ritchard C Rosen1, Alan C Stuto2* and Keith D Cook3
1Department of Podiatric Surgery, Holy Name Medical Center, USA
2Department of Podiatric Surgery, University Hospital, Newark NJ, USA
3Department of Podiatry, University Hospital, Newark, NJ, USA
*Corresponding author: Alan C Stuto, Department of Podiatric Surgery, Holy Name Medical Center, Teaneck, NJ, 07666, USA
Published: 25 Apr, 2017
Cite this article as: Rosen RC, Stuto AC, Cook KD. Group
a Streptococcus Necrotizing Soft Tissue
Infection Secondary to Corticosteroid
Injection: A Case Report and Literature
Review. Clin Surg. 2017; 2: 1431.
Abstract
The use of corticosteroid injections is a common practice for foot and ankle pathology. The incidence of infection or necrotizing fasciitis following injection therapy is rare. Necrotizing soft tissue infections may be fatal or cause limb loss. The authors present a rare case of group A streptococcus necrotizing fasciitis following corticosteroid injections into a patients bilateral ankle joints. The authors discuss the emergent treatment that prevented limb loss, a review of the literature and recommendations for prevention of infections following corticosteroid injection.
Introduction
Corticosteroid injection therapy is a common treatment modality for many foot and ankle
pathologies. Preparation of the skin prior to joint injection widely varies among disciplines and
across regional borders, likely due to the paucity of literature on the most effective and efficient
methods of preparation [1]. Regardless the incidence of post-injection infection remains low, with
the incidence varying from 1:3,000 to 1:50,000 injections [1]. Baima “et al.” report that intra-articular
infections post-injection is not common. In the podiatric practice, povidone-iodine or alcohol based
solutions are the standard prior to injection of a joint [2].
Group A Streptococcus (GAS; Streptococcus pyogenes) is an aerobic gram-positive coccus
organism that causes an array of infections including cutaneous infections such as cellulitis,
erysipelas, pyoderma, necrotizing fasciitis, myositis or myonecrosis. In addition pharyngitis,
rheumatic fever; acute glomerulonephritis, pneumonia, postpartum endometritis and toxic shock
syndrome have been attributed to Group A Streptococcus [3]. The purpose of this paper is to review
Group A Streptococcus bacteria and report a rare case of Group A Streptococcus infection following
corticosteroid injection into the ankle joint, bilaterally.
Materials and Methods
A 56 y/o female was admitted to the hospital thirty-six h after receiving a corticosteroid injection
to her left and right ankles. The patient stated when she got home that night she developed pain and
redness to both ankles. Her physician prescribed her amoxicillin/clavulanic acid and oxycodone/
acetaminophen. Within hours the pain became “so severe to both ankles” and the redness had
progressed proximally up her left leg and thigh. She subsequently presented to the emergency room
the following day and was admitted to the hospital.
Upon examination in the emergency department pain was present to her bilateral ankles, left
lower leg, thigh and groin. The patient was able to perform active range of motion to both lower
extremities with significant pain to left ankle joint. Infectious disease was consulted immediately in
the emergency department. Clinically the patient presented with an extremely edematous left foot
and ankle and with mild edema noted to her right ankle. Pain was present upon palpation of the
right ankle, left foot, left ankle and left groin regions. No crepitus was noted with superficial or deep
palpation. The most significant pain upon palpation was present to left ankle joint.
Erythema was present spanning the dorsal left foot/ankle along with the medial aspect of the
left leg and thigh. On the right ankle erythema was isolated to the anteromedial aspect of the ankle.
There was a large serosanguinous bulla dorsally on the left foot over metatarsals three through five and extending to the lateral aspect of entire heel. (Figure 1) The
patient was started on IV vancomycin and ceftriaxone.
Significant labs upon admission: WBC 22,000 × 103/μL; Absolute
neutrophil 20.2 × 103/μL; Band neutrophils 26%; Lymphocytes 4%;
Lactic acid 3.4 mmol/L; CRP 23.9 mg/L; ESR 70 mm/hour, Glucose
102 mg/dL; Temp 102.4°F. On hospital day two, her WBC decreased
to 18,000 × 103/μL and her temperature remained elevated at 102.2°F.
Podiatry was consulted at this time for evaluation and management
of the ankles bilaterally. The clinical appearance had not changed
as stated above. Foot, ankle, and tibia-fibula X-rays bilaterally were
obtained which revealed no soft tissue gas or signs of osteomyelitis.
The patient was determined to have a septic left ankle joint and
cellulitis to right anterior ankle based upon clinical examination.
The patient was emergently taken to the operating room. An
incision and drainage of the patient’s left foot and ankle with left
ankle arthrotomy was performed. Approximately 60 milliliters of
serosanguinous fluid was expressed from the left ankle and dorsal foot
incisions. No purulence was expressed. Pulse lavage was performed
with three liters of normal saline and three liters of normal saline
mixed with polymyxin B and bacitracin. Pre and post lavage wound
cultures were obtained and sent to microbiology. Pre lavage soft
tissue was sent to pathology for evaluation of cells and for cell count.
Figure 1
Figure 1
Initial presentation of LE b/l. A) Dorsal edema, erythema,
ecchymosis, and serosanguinous bullae noted. B) Ascending cellulitis noted
to medial aspect foot, leg and thigh. C/D) Right ankle localized erythema.
Figure 2
Figure 2
S/p day #2 after initial surgery. Necrotic tissue noted to dorsum foot
and localized cellulitis remained. (4 incisions from initial surgery are shown:
anteromedial ankle, anterolateral ankle, dorsal proximal foot and dorsal distal
foot).
Figure 3
Figure 3
S/p day #7 after 2nd debridement shows that all necrotic/non-viable
tissue was removed from left foot and ankle.
Figure 4
Figure 5
Figure 6
Figure 7
Results
On hospital day three, the patient’s WBC decreased to 14,000
× 103/μL. The patient was able to move her toes without pain but
had mild pain with left ankle joint motion. On hospital day 4, the
WBC decreased to 7,000 × 103/μL and her clinical exam remained
unchanged. At this time, the cellulitis was no longer present to the patient’s left thigh and leg. The cellulitis to her right ankle had also
resolved. Wound cultures from the OR revealed Group a Strep
(pre lavage only) and the patient were started on IV penicillin G as
per infectious disease recommendations. Normal saline wet to dry
dressings were applied to all wounds and changed daily.
A second debridement in the operating room was performed
to remove any remaining non-viable tissue (Figure 2). Post lavage
wound cultures were again obtained. The wound demonstrated
healthy granular tissue following the second surgery and daily wet to
dry dressing changes were continued for another week. No clinical
signs of infection were noted and finalized post lavage wound cultures
were negative (Figure 3).
The patient was subsequently taken to the operating room
two weeks after the second debridement for application of a split
thickness skin graft. The graft was harvested from the ipsilateral thigh
with the assistance of a general surgeon and applied to the dorsum of
the left foot and ankle (Figure 4). Following this surgery the patient
was discharged from the hospital in stable condition and followed up
with the surgeon until complete healing of left foot (Figure 5-7). The
patient remained on antibiotics for a total of three weeks; two weeks of
IV antibiotics and then converted to oral penicillin for an additional
week. The complete healing of the skin graft was eight weeks post
operatively and two weeks later the patient resumed normal shoe
gear. The patient began physical therapy for mobilization of the graft
and adjoining tissue. After two weeks of treatment, she was cleared by
physical therapy and resumed full activity.
Discussion
Corticosteroid injection therapy into a joint is common practice
for a foot and ankle surgeon. As one can see from the case presented
significant complications may arise. Adequate skin preparation is
vital, and we recommend utilizing sterile technique before performing
a joint injection. Although it is nearly impossible to replicate sterile
procedures outside of the operating room, Baima “et al.” defines sterile
technique for joint injections as utilizing sterile gloves and preparing
the skin of the injection site with povidone-iodine or chlorhexidine
solution prior to injection. We believe this is vital in the prevention
of post injection infection in comparison to “clean technique with
non-sterile gloves” [1]. The use of single dose vials of an injectable
may be beneficial in the reduction of post injection infections, and
should be common practice. In our case report the suggestive cause of
infection was the use of a multi-dose vial. It could not be determined
the technique for sterility utilized for the injections [4].
Necrotizing soft tissue infections are rare but can be very severe
resulting in extremity loss or death. Based on microbiological
characteristics necrotizing soft tissue infections are classified into three types: Type I (Polymicrobial infection), Type II (Group A
Streptococcal [GAS] infection), Type III (Clostridium organisms,
most commonly Clostridium Perfringens). There are also case reports
of monomicrobial necrotizing soft tissue infections due to other
organisms, including Vibrio Vulnificus, Aeromonas Hydrophilia, and
Haemophilus Influenzae [6].
Treatment of necrotizing soft tissue infection consists of early
and aggressive surgical exploration and debridement of necrotic
tissue, together with broad-spectrum empiric antibiotic therapy and
hemodynamic support. Surgery is indicated in the setting of severe
pain, toxicity, fever or an elevated serum creatine kinase (CK) level,
with or without radiographic evidence of soft tissue emphysema [7].
Use of antibiotic therapy without debridement is associated with a
mortality rate approaching 100 percent [7]. Hemodynamic instability
may require aggressive supportive care with fluids and vasopressors.
Necrotizing infections of the skin and fascia are surgical
emergencies. Radiographic imaging studies should not delay surgical
intervention when there is crepitus on examination or clinical
evidence of progressive soft tissue infection. The goal of operative
management is to perform aggressive debridement of all necrotic
tissue until healthy, viable tissue is reached [6]. Tissue obtained
in the operating room should be sent for Gram stain, culture and
pathological examination [6]. Subsequently, the wound should be
covered with a sterile dressing, reevaluated approximately 24 to 48
hours later, and aggressively debrided again if necrotic tissue is present
[6]. The wound may be closed or grafted after all necrotic tissue is
completely debrided. In some cases, allografting or myocutaneous
tissue reconstruction is required to cover the defect.
Treatment of group a streptococcus infections consists of
penicillin G (4 million units intravenously every four hours in patients
with normal renal function) [8]. One can add clindamycin (900 mg
IV every eight h) to penicillin therapy or use it as an isolated antibiotic
therapy if culture sensitivities indicate as an effective treatment option
[8]. Although there are no additive, synergistic, or antagonistic effects
of penicillin when added to clindamycin in vitro, clindamycin alone
has been found to be more effective in invasive infections [8]. Unlike
penicillin, the efficacy of clindamycin is unaffected by the size of the
inoculum and stage of bacterial growth [8]. In addition, clindamycin
inhibits the production of toxin by streptococci.
The optimal duration of antibiotic therapy for GAS bacteremia
is uncertain, and data is limited. In general, antibiotics should be administered for at least 14 days [8]. The clinical approach should
be tailored to individual patient circumstances, including the source
of infection and clinical response to treatment. In the setting of
serious soft tissue infection antibiotic therapy is generally continued
for 14 days from the last positive culture obtained during surgical
debridement [8]. It is uncertain whether intravenous therapy is
required for the entire duration of antibiotic therapy, and data is
limited on this as well. Following clearance of bacteremia if present,
completion of surgical intervention and resolution of clinical signs of
infection, it may be reasonable to complete the course of antibiotic
therapy with an oral agent [8].
References
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- Southerland J. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 4th edn. John Schuberth, Jerome Steck, editor. Jeffrey Christensen. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins. 2012;728.
- Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis. 1992;14(1):2-11.
- Siegel J, Rhinehart E, Jackson M, Chiarello L. “2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.” Am J Infect Control. 2007;35(10):65-164.
- Kiska DL, Thiede B, Caracciolo J. “Invasive group A streptococcal infections in North Carolina: epidemiology, clinical features, and genetic and serotype analysis of causative organisms.” J Infect Diseases. 1997;176(4):992-1000.
- Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36.
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- Khan ZZ. Group A Streptococcal Infections Treatment & Management. Medscape. 2016.