Streptococcal Toxic Shock Syndrome in a Patient with a Phlycten

A 74-year-old female with diabetes mellitus type 2 was admitted to the emergency department due to fever, severe pain and oedema in her left forearm, with two days of evolution, after she has done gardening, but no clear history of trauma. At clinical examination, the patient presented hypotension, fever and a hematic phlycten on her left forearm, which was tense to palpation (Figure 1A). Laboratory investigation revealed an elevated C-reactive protein of 386 mg/L, creatine kinase of 13616 U/L and myoglobin of 3269 ug/dL. In addition, acute kidney injury co-occurred with creatinine 2.07 mg/dL and arterial lactate 3.11 mmol/L. Fluid therapy and empirical antibiotic were initiated with piperacillin/tazobactam, clindamycin and vancomycin, after blood cultures had been collected, and surgical debridement and fasciotomy were performed (Figure 1B). After the surgery, the patient was admitted to the Intensive Care Unit (ICU) with evident deterioration and haemodynamic instability. She maintained intubated and was initiated vasopressor support in high doses. The patient provided her written informed consent for presenting the case and the images.