Axillary Abscess Complicated by Venous Thrombosis: Identification ofStreptococcus pyogenesby 16S PCR

Abstract

We report a case of an axillary abscess with Streptococcus pyogenes complicated by venous thrombosis. Bacterial etiology and typing were obtained by PCR and sequencing of the 16S rRNA and M-protein genes from abscess material. The bacterium was of serotype M41, and serology indicated that it had expressed procoagulant factors. CASE REPORTA 62-year-old woman presented at our department with a 7-day history of fever, chills, and nausea. She was previously healthy, apart from having atopic eczema, and she worked as a technician in a microbiology department handling bacterial specimens. For some months, she had experienced pain in the left part of her thoracic wall, which she related to repetitive movements. Two days prior to admission, she started to feel pain in her left axilla. On the day of admission, she had vomited and suffered from diarrhea. At admission, she had a temperature of 39.5°C. The routine physical examination was normal, except for a slight tenderness upon palpation of the left axilla. There were no signs of erysipelas, lymphangitis, or enlarged lymph nodes in the axilla. Laboratory investigation revealed a white blood cell count of 18 ϫ 10 9 /liter (the neutrophil count was 17 ϫ 10 9 /liter), a C-reactive protein (CRP) level of 53 mg/liter, and normal renal and liver function test results. Coagulation test results were within normal limits, with a PT(INR) [prothrombin time (international normalized ratio)] of 1.1, an aPTT (activated partial thromboplastin time) of 36 s, and a platelet count of 329 ϫ 10 9 /liter. After two aerobic and two anaerobic blood cultures (BacT/Alert; bioMérieux, Durham, NC) and a urinary culture were obtained, the patient was sent home and told to return if she got worse. No antibiotics were prescribed. Blood cultures turned out negative.Seven days later, the patient returned with persistent axillary pain and intermittent chills and was hospitalized. Her body temperature fluctuated between 38.0°C and 39.9°C in the following days. Her white blood cell count was 21 ϫ 10 9 /liter (her neutrophil count was 19 ϫ 10 9 /liter), and her CRP level was 393 mg/liter. Upon examination of the axillary region, pain was provoked by palpation but no enlarged lymph nodes or suspected abscesses were felt and no signs of arthritis were noted. Treatment with cefuroxime and clindamycin was instituted due to suspicion of a soft-tissue infection in the axillary region. A plain X-ray of the shoulder showed degenerative changes in the acromio-clavicular joint, and ultrasonographic examination of the axilla was normal, with no signs of edema in the musculature or in the subcutaneous layer and no signs of abscess. A slight improvement occurred over the following days. Renewed blood cultures taken at the time of admission turned out negative. On the 6th day after admission, a swelling of the left arm developed and venous flebography confirmed the presence of a venous thrombosis in the axillary vein. Coagulation tests were done and showed a PT(INR) of 1.1, an aPTT of 40 s, and a platelet count of 430 ...

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