We report the case of a 42 years-old woman who presented to the emergency department of the peripheral hospital of Scandiano (RE) on March 2, 2019 for an atraumatic pain in her right shoulder. She has a silent medical history and no history of drug use.
She reports waking up in the morning with worsening shoulder pain associated with functional impotence. The patient also reports a low-grade fever 2 days earlier, without cough or dysuria, spontaneously resolved.
At the first clinical evaluation of the patient in the ER she was apyretic, complaining only about the pain in the shoulder, without cutaneous rush or deficiency of the peripheral nerves.
She strongly denies recent trauma. The orthopedic specialist evaluated the woman and diagnosed a cervicobrachial neuralgia. After the administration of 1g of paracetamol the pain disappears and the patient has been discharged with the suggestion of taking NSAIDs. After 24 hours, patients return to the ER of Scandiano, complaining again pain in the right shoulder with pain irradiation also in the right lumbar region. She was still apyretic.
The clinical examination highlighted an important muscular contraction of the shoulder ("as hard as marble"), associated with whitish color of the shoulder skin and a small area of violaceous color at the axillary level.
The patient was treated with intravenous analgesic and biohumoral tests were performed. Pending the results of the exams, we detected hypotension (PA 80/60), treated with a liquid infusion.
An ultrasound was performed, which reasonably excluded aortic dissection (no pericardial effusion, normal aortic box, no dilation of the abdominal aorta, no pleural or endoabdominal effusions).
The blood gas analysis showed the presence of metabolic acidosis with high lactates.
Finally the blood tests showed: Leucocytes 3.66 x1000; Hb 9 g / dl, PLT 197 x1000, Glucose 105 mg/dl. Na 133 mmol / lt. Creatinine 2.44 mg/dL, C-reactive protein 29 mg / dL (normal range 8 – 30 mg/dL), procalcitonin 14.5 ng / ml.
If we apply the LRINEC score3-4 to this patient the result is 10 points: high risk.
According to the LRINEC score: ​​<5 points is a low probability of NF; 6-7 points is an intermediate risk, > 8 points suggest an high risk of NF. A CT scan and advice from the infectious disease specialist are not available at the peripheral hospital at night and at weekends. For this reason our patient has been centralized in the Hub center of Reggio Emilia, where she has performed blood cultures and a CT of the neck and thorax, that identified inflammatory imbibition of the laterocervical soft tissues of the right hemithorax and mediastinal adipose tissue.
Despite the rapid volume filling, after few hours the patient was still hypotensive and it was necessary to give her an infusion of noradrenaline.
She also started antibiotic therapy with daptomycin + meropenem + clindamycin and was admitted to the operating room for soft tissue debridement surgery. Blood cultures and microbiological analysis of intraoperative tissue samples were all positive for streptococcus beta-haemolytic group A piogenes group A beta-hemolytic associated with toxic shock syndrome toxin (TSST).
After 3 days a new incision was necessary for debridement surgery and positioning of negative pressure wound therapy (NPWT).
On the fifth day she performed a lower limb compression ultrasound (CUS) that evidenced a thrombosis of the sural vessels in the middle III of the right calf, and a therapy with LMWH (Low molecular weight heparin) was initiated. One month later the patient was discharged in excellent condition, after a brief cycle of physical rehabilitation (due to protracted bedding).
In conclusion we assume that axillary hair removal is likely to be the cause of this infection.