Saijo Yusaku, Ono Shimpei, Akiyama Goh, Sugii Masataka, Kodama Yoshihiro, Nukaga Sawako, Yokobori Shoji, Ogawa Rei
From the Department of Plastic Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan.
Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan.
Plast Reconstr Surg Glob Open. 2025 Jun 25;13(6):e6917. doi: 10.1097/GOX.0000000000006917. eCollection 2025 Jun.
Group A streptococcal necrotizing soft tissue infection (GAS-NSTI) is a severe condition that can be complicated by streptococcal toxic shock syndrome. Management necessitates multidisciplinary care, including emergency medicine, surgery, plastic surgery, and infectious diseases. Early diagnosis and appropriate therapeutic intervention are essential for GAS-NSTI, as effective prevention strategies have not been established. However, it is often misdiagnosed as cellulitis, resulting in delayed treatment.
In a single-center retrospective study, 25 patients with GAS-NSTI were analyzed for initial symptoms, vital signs, quick sequential organ failure assessment (qSOFA), and blood test results, comparing those with early-stage (≤3 d) and later-stage (≥4 d) GAS-NSTI.
Twelve patients had their first blood test done 3 days or less (early) after first symptom awareness. The remaining13 patients had their first blood test done at 4 or more days (later) after symptom onset. Early-stage GAS-NSTI showed elevated C-reactive protein (CRP) levels (34.0 ± 11.2 mg/dL) but normal white blood cell (WBC) counts (6.7 ± 4.9/μL), whereas later-stage cases had elevated CRP (29.7 ± 9.0 mg/dL) and WBCs (18.6 ± 10.1/μL, < 0.001). Seven patients (28%) had a laboratory risk indicator for necrotizing fasciitis (LRINEC) score of 5 or more points (4 from the early-stage group and 3 from the late-stage group). Nineteen patients (76%) had a negative qSOFA score at the initial outpatient visit.
In addition to soft tissue symptoms, elevated creatinine and blood urea nitrogen levels, and thrombocytopenia, high CRP levels with normal WBCs should raise suspicion of early GAS-NSTI, even when laboratory risk indicator for necrotizing fasciitis and qSOFA scores are negative.
A组链球菌坏死性软组织感染（GAS-NSTI）是一种严重疾病，可并发链球菌中毒性休克综合征。其治疗需要多学科护理，包括急诊医学、外科、整形外科和传染病学。由于尚未确立有效的预防策略，早期诊断和适当的治疗干预对GAS-NSTI至关重要。然而，它常被误诊为蜂窝织炎，导致治疗延误。
在一项单中心回顾性研究中，分析了25例GAS-NSTI患者的初始症状、生命体征、快速序贯器官衰竭评估（qSOFA）和血液检查结果，比较早期（≤3天）和晚期（≥4天）GAS-NSTI患者的情况。
12例患者在首次意识到症状后3天或更短时间（早期）进行了首次血液检查。其余13例患者在症状出现后4天或更长时间（晚期）进行了首次血液检查。早期GAS-NSTI患者C反应蛋白（CRP）水平升高（34.0±11.2mg/dL），但白细胞（WBC）计数正常（6.7±4.9/μL），而晚期患者CRP（29.7±9.0mg/dL）和WBC升高（18.6±10.1/μL，P<0.001）。7例患者（28%）坏死性筋膜炎实验室风险指标（LRINEC）评分达到或超过5分（早期组4例，晚期组3例）。19例患者（76%）在初次门诊就诊时qSOFA评分为阴性。
除软组织症状、肌酐和血尿素氮水平升高以及血小板减少外，即使坏死性筋膜炎实验室风险指标和qSOFA评分均为阴性，CRP水平升高而WBC正常也应引起对早期GAS-NSTI的怀疑。
