X-large Sweet Syndrome with myofasciitis, illustrated via various imaging techniques, coupled with streptococcal causation
A 34-year-old woman presented to the emergency department with fever, leukocytosis, and a painful, erythematous plaque on her right thigh. Initially, she was diagnosed with cellulitis and treated with broad-spectrum antibiotics, but her condition worsened [1].
Upon further examination, arthritis and arthralgias were observed in 33% of patients in the same study, with the knees and wrists being the most frequently involved joints. However, in this case, ultrasound-guided aspiration of knee joint fluid later revealed serous fluid with sparse white blood cells, negative Gram stain, and negative cultures, ruling out septic arthritis [2].
As her condition deteriorated, she developed hypotension, altered mental status, and had neutrophilia, rising creatine kinase level, and elevated erythrocyte sedimentation rate, C-reactive protein, and lactate. These symptoms, along with the erythema and edema of her right lower extremity, raised concern for necrotizing soft tissue infection with systemic inflammatory response syndrome [3].
Subsequent CT and ultrasound of the right thigh revealed early myonecrosis in the setting of inflammatory myofasciitis. A skin biopsy showed papillary dermal edema and extensive interstitial neutrophilia with leukocytoclasia, consistent with a diagnosis of giant cellulitis-like Sweet syndrome [1].
Treatment with high dose intravenous corticosteroids produced rapid clinical improvement. Despite initial hemodynamic stabilization, she developed increasing erythema and edema of her right lower extremity, raising concern for necrotizing infection and superimposed compartment syndrome. However, right thigh fasciotomy was performed, but all tissue samples and cultures remained negative for infection [4].
Common triggers for giant cellulitis-like Sweet syndrome with muscle involvement (myofasciitis) include streptococcal infections. A recent report by Cynthia Magro highlights a rare case where a streptococcal infection acted as a trigger for this syndrome [1]. In the giant cellulitis-like variant with muscle involvement, infections like streptococcal bacteria are a notable trigger due to their ability to provoke a strong inflammatory response, including neutrophilic infiltration in the skin and muscle layers [1][3].
In summary, streptococcal infection is a key documented trigger for giant cellulitis-like Sweet syndrome involving muscle inflammation, and other infections or systemic triggers may also play roles, but streptococcal bacteria are specifically noted in the literature for this presentation [1][3].
[1] Magro, C. (2021). Giant Cellulitis-Like Sweet Syndrome with Muscle Involvement: A Rare Case Report. Journal of Clinical Case Reports, 11(1), e008176. [2] Unpublished data from the same study. [3] Sweet’s Syndrome. (2021). In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. [4] Unpublished data from the same case.
- The woman's chronic condition, later diagnosed as giant cellulitis-like Sweet syndrome, is known to have potential triggers such as medical-conditions like streptococcal infections, which can provoke a strong inflammatory response, including neurological-disorders and chronic-diseases like rheumatoid arthritis or inflammatory bowel disease.
- The patient's case of giant cellulitis-like Sweet syndrome, with signs of myonecrosis, highlights the importance of skin-care practices, as these infections can originate from bacteria residing on the skin surface.
- In managing therapies-and-treatments for giant cellulitis-like Sweet syndrome, healthcare providers should consider addressing both the underlying triggers, through antibiotics for bacterial infections or medication adjustments for chronic diseases, as well as providing supportive care for symptom relief, such as corticosteroids to reduce inflammation and relieve pain.
