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 prescribed 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 erythrocyte 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 maxillary 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 infections 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 of Group A Streptococcus infections and the need for high doses of antibiotics and early debridement to achieve the best outcome.