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Case of the Month - January 2016

Jade Mogambery1, Sumayya Haffejee2, Halima Dawood1

1Grey’s Hospital, Department of Internal Medicine, Infectious Diseases Unit and University of KwaZulu Natal. 2 Department of Microbiology, Northdale Pathology Laboratory, NHLS, Pietermaritzburg and University of KwaZulu Natal

A 28-year old HIV-seronegative woman was referred to the Obstetrics department of a tertiary care hospital from a district health facility. She presented with a swollen knee, hypotension and fever a week after delivering a healthy baby by normal vaginal delivery. She required an episiotomy in order to facilitate the delivery process.
Blood cultures where taken at the district health facility and she was referred for further management to the intensive care unit after a diagnosis of septic shock was made. Puerperal sepsis was considered but following a gynecological examination and imaging this was excluded.
She developed renal impairment with a creatinine of 251 umol/L (50 - 90 umol/L). The international normalized ratio was elevated and the platelet count was less than 100,000/mm3. There was evidence of liver dysfunction with a bilirubin level that had increased to 123 umol/L (<26 umol />L) and transaminases that were more than two times the upper limit of normal.
Following clinical deterioration she required both ventilatory and inotropic support for hypoxia and hypotension respectively. Twenty four hours after admission to the intensive care unit, purpuric lesions developed on the lower limbs and a clinical diagnosis of necrotizing fasciitis was made.
The blood culture, taken at the district health facility, grew a Group A Streptococcus (Streptococcus pyogenes) that was sensitive to penicillin and clindamycin. She was commenced on these antibiotics and was taken to theatre for debridement of the soft Streptococcus tissue. She subsequently required a skin graft and recovered without any further complications.

Question 1: What complication of Group A Streptococcus infection did this patient develop and what are the diagnostic criteria?

Continue to Answer 1