Case Reports

The index patient was a homeless 34-year-old Native American female with a history of alcoholism who presented to the emergency department on 9 February 2005 (at 8:43 pm) complaining of weakness, arthralgias, and vomiting, with severe left leg, hip, and back pain. The leg pain developed after a vaguely recalled fall during the previous week. A moderate cough with greenish sputum was reported without a sore throat for a few days before admission to the hospital. She was actively menstruating but did not use tampons. There was no significant medical history or allergies. The patient's blood pressure was 62/40 mm Hg, her pulse was 141 beats/min, her respiratory rate was 22 breaths/min, and her temperature was 38.1°C. She was acutely ill and in distress because of pain. The head, neck, cardiopulmary, and abdominal examination findings were unremarkable. She had mottled, cool extremities with an ecchymotic and tender left thigh without crepitus or bullae. Chest, pelvic, and left femur radiograph findings were normal, as were urine analysis findings. No sputum or throat swab samples were obtained for culture. The patient's WBC count was 9600 cells/mm³(with 25% neutrophils and 24% band forms), her creatine phosphokinase level was 4294 U/L, and her creatinine level was 2.4 mg/dL. The total bilirubin level was 0.8 mg/dL, and levels of hepatic transaminases were moderately elevated. Blood cultures were performed. She remained hypotensive despite fluid infusions with >5 L of saline and became less responsive after receiving morphine therapy. At 9:26 pm, the patient received 2 g of ceftriaxone intravenously (IV), underwent endotracheal intubation for mechanical ventilation, and received vasopressor agents. A surgical consultant performed a bedside thigh muscle biopsy at 11:30 pmand concluded that there was no sign of infection. The consultant sent a biopsy sample for microbiologic studies and recommended adding aztreonam (2 g IV every 8 h) and clindamycin (900 mg IV every 8 h) to the treatment regimen. The patient was transferred to an intensive care unit and was seen by an infectious diseases consultant the next day at 10:00 am. The infectious diseases consultant observed mottling of both legs, primarily proximally. The left thigh was indurated 50% larger than the right, with extension of hemorrhagic and violatious mottling in the proximal left thigh, inguinal, and mons area. A wound specimen for Gram stain and culture that was obtained from the biopsy lesion showed few neutrophils and gram-positive cocci. Surgical debridement was advised. Clindamycin and ceftriaxone therapy was continued. Blood and wound specimens were positive for GAS within 24 h after obtainment. Approximately 16 h after presentation, the patient had left hip disarticulation caused by massive thigh myonecrosis. Specimens obtained intraoperatively were still positive for GAS. Contact precautions (gloves and gowns when entering the patient's room) were implemented at admission to the intensive care unit and were maintained for the course of therapy. Postoperatively, the patient received IV immunoglobulin (50 g every 6 h for 4 doses) and required several more debridement procedures of the lower abdomen and pubic area. She improved and was extubated on hospital day 12. After skin graft and flap procedures, the patient was discharged to a rehabilitation hospital on day 52.

The second case occurred in a 53-year-old African American male respiratory therapist who presented to the same hospital emergency department on 15 February 2005 (at 8:55 pm) with nearly a week of cough; dyspnea, which acutely worsened on the day of presentation; pleuritic chest pain; and fever. He had a mild sore throat. He worked at the hospital where the index patient was admitted, including in the intensive care unit. He did not use alcohol, illicit drugs, or tobacco and did not have a relevant medical history. His wife and son had mild cold symptoms for several days before the HCW's illness. At presentation, his blood pressure was 115/70 mm Hg, his pulse was 115 beats/min, and his temperature was 35.3°C (orally). His respiratory rate was 22 breaths/min, with gasping, and the room air oxygen saturation was 85%. There was no pharyngitis or exudate. The chest had left rales, but the remainder of the examination findings were unremarkable. A portable chest radiograph revealed a left lower lobe infiltrate. The peripheral WBC count was 12,900 cells/mm³(with 57% neutrophils and 21% bands), the serum creatinine level was 3.1 mg/dL, and the total bilirubin level was 1.8 mg/dL; transaminase levels were normal, and the alkaline phosphatase level was 170 U/L. A sputum specimen showed neutrophils and gram-positive cocci in chains. Blood cultures were performed, and ceftriaxone (1 g IV) and azithromycin (500 mg IV) therapy was administered. The HCW's systolic blood pressure decreased to 95 mm Hg despite crystalloids. Respiratory failure ensued, requiring endotracheal intubation and mechanical ventilation at ∼3 h after presentation. He was admitted to the intensive care unit and received an additional 1 g of IV ceftriaxone and 1 g of vancomycin. The blood and sputum culture grew GAS isolates that were susceptible to macrolides and penicillin. Complications included ventilator-associated pneumonia and gastrointestinal bleeding. While still receiving mechanical ventilation, the HCW was transferred to a rehabilitation facility 50 days after his presentation. In 2007, he returned to work full time as a respiratory therapist.