8 Thoracic necrotizing fasciitis with toxic shock due to S. pyogenes, case series
Authors: Landero Leonidas , Lopez Raul Guerrero , Xaus Marc Perez , Planas Sara Fernandez , Al Ashtar Wassim , Guimera David Martinez , Navarro Rebeca , Vallverdú Helena 
Published: February 2025

Abstract

Necrotizing fasciitis (NF) is a severe bacterial soft tissue infection primarily affecting muscle fascia and subcutaneous tissue. In Europe, it has an annual incidence of 3–5 cases/100 000, with a mortality rate of 10–15% (rising to 38–45% in septic shock). Risk factors include hypertension, immunosuppression, diabetes, obesity and trauma. NF commonly occurs in the extremities and perineal region and less frequently in the chest. In monomicrobial cases, Streptococcus pyogenes is the most frequently identified. Treatment involves hemodynamic management, intravenous antibiotics, and early surgical debridement; multiple procedures may be necessary. Clinical presentation is nonspecific. Prognosis relies on swift diagnosis and early surgical intervention. We present a case report of three thoracic NF.

Case 1
A 67-year-old woman with cardiovascular comorbidities presented to the emergency room with right shoulder pain following a fall. Diagnosed with a right clavicle fracture, she was discharged the same day with conservative management. Patient returned 24 hours later with decreased consciousness, dyspnea, and ecchymotic plaques on the right shoulder and breast. Suspecting septic shock, meropenem and linezolid were initiated. Chest CT: thickening of the pectoral fascia and subcutaneous tissue trabeculation. Urgent surgical debridement confirmed necrotizing fasciitis of the right pectoralis major muscle with cervical extension. After the excision of necrotic tissue, the patient was admitted to the ICU. The progressive ecchymotic zone prompted a second intervention, including a right mastectomy. Microbiology reported Streptococcus pyogenes multisensitive. Negative pressure wound therapy was used after surgeries. A mesh skin graft was performed after 40 days, and discharge followed after 50 days.

Case 2
A 38-year-old man with non-medical history presented to the emergency room with 3 days of fever and right-sided chest pain. He had a wooden splinter in his right hand. Signs of septic shock and erythematous skin over the right pectoral region were evident. Empirical antibiotic treatment began, and chest CT indicated NF of the right pectoralis major fascia. Extensive debridement of the right hemithorax, right arm inner side, mastectomy, and axillary lymphadenectomy were performed. Postoperatively, the patient entered the ICU. Microbiology identified Streptococcus pyogenes multisensitive. Negative pressure therapy led to a satisfactory recovery. Skin grafting from the proximal regions of both lower limbs occurred after 48 days of hospitalization, and the patient was discharged after 60 days.

Case 3
A 45-year-old man with chronic renal failure and peripheral vascular disease presented to the emergency room with 4 days of right chest pain, fever, and dark sputum, indicating septic shock. Chest X-ray revealed right pneumonia. Within hours of ICU admission, a necrotic plaque appeared on the right pectoral region. Thoracic CT showed NF. Urgent surgical debridement removed necrotic tissue from the right para-sternal region to the posterior axillary line. Microbiology identified Streptococcus pyogenes multisensitive. Despite initial recovery, the patient succumbed to vascular complications 4 months later.

Conclusion
Necrotizing fasciitis is an infection with high morbimortality. It requires high suspicion diagnostic suspicion and early treatment based on broad-spectrum antibiotics, management of septic shock and early surgical debridement. Multidisciplinary management is crucial to improve these patients' survival and quality of life.