Sunday, February 07, 1999
Dr. Dow described the case of a 35-year-old diabetic who spontaneously developed, without injury or antecedent infection, painful calf swelling. "Over a period of 48 hours, his only positive physical findings and symptoms were calf swelling and tenderness with a negative ultrasound for deep venous thrombosis and negative blood cultures," said Dr. Dow, associate clinical professor, Nevada School of Medicine, Reno, Nev. "At 48 hours, the patient became acutely dyspneic and expired.
"An autopsy revealed Group A Beta Hemolytic Strep, septicemia, gangrenous necrosis of calf muscle and, as a cause of death, multiple pulmonary emboli, the etiology of which was not demonstrated. Autopsy did not reveal a source for the emboli, in either the leg veins or in the pelvis, but was very strongly suggestive of a right cardiac etiology for the emboli."
Gangrenous streptococcal myositis is a very severe and fulminant form of pyomyositis associated with a more rapidly progressive course and a much worse prognosis than either pyomyositis or necrotizing fasciitis, Dr. Dow said. Fewer than 30 cases of gangrenous strep myositis have been reported in the English literature with more than 80 percent mortality. It is characterized by a rapidly progressive course with toxic shock and death within a few days of onset of symptoms. Dr. Dow said no previous case has been reported where the cause of death was multiple pulmonary emboli.
It is important to distinguish gangrenous myositis from the equally rare (37 reported cases), but much more benign condition of diabetic muscle infarction which may present with an identical early clinical picture, he said.
"In nearly all of the reported cases, there was a delay in establishing the diagnosis within the first two to three days of the clinical course, with the result that by the time the diagnosis was established, the patient was manifesting symptoms of toxic shock and multiorgan failure," he said. "In this case, before the patient had a chance to develop symptoms of toxic shock syndrome, he expired with multiple pulmonary emboli."