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INTERESTING CASE: Bilateral necrosis of the eyelids induced by streptococci

A 40-year-old woman presented with a 3-day history of bilateral facial swelling, pain,
and fever. Her treatment included oral lithium, and flucloxacillin that had been pre-
scribed 24 h earlier by a general practitioner.
On examination she had a high fever and bilateral blisters on the lower eyelids and
right upper eyelid that progressed to skin necrosis within 48 h (Figs. 1 and 2). The ery-
throcyte sedimentation rate in the first hour was 86 mm/h (Reference Range < 20), and
the white cell count was 20 × 109 L−1 (Reference Range 4–11). A computed tomogram
showed a right maxillary polyp and mild inflammation of the left ethmoid and maxil-
lary antrae. She was given high doses of intravenous penicillin G, and flucloxacillin and
clindamycin were added when sensitivities were known. Initial wound swabs showed
Gram-positive cocci and cultures grew Group A streptococci. The necrotic skin was
debrided and the wounds were eventually closed with local temporal transposition
flaps.
Although rare, the incidence of Group A streptococci-induced necrotising infec-
tions has increased over the past 20 years. The face is rarely affected and elderly patients
are particularly at risk. Rapid progression to renal failure and septic shock leads to an
overall mortality of between 17% and 33%, and delayed debridement of necrotic tissue
considerably increases mortality. This case highlights the severe and rapid progression Fig. 2. Swelling rapidly progressed to skin necrosis.
of Group A Streptococcus infections and the need for high doses of antibiotics and
early debridement to achieve the best outcome.
John L. Kelly
David Morgan
James Burt

Fig. 1. Facial appearance at presentation.