Fulminant Necrotizing Fasciitis And Myositis With Streptococcal Toxic Shock Syndrome In A Patient With Rheumatoid Arthritis On Tocilizumab: A Case Report

Introduction: We present the case of a 44-year man with a fulminant necrotizing myositis and fasciitis and streptococcal toxic shock syndrome, the patient being under treatment with tocilizumab and methotrexate for rheumatoid arthritis. Case presentation: He presented to the emergency department with diarrhea, flu-like symptoms and intense progressive pain in the right thigh after having shoveled while doing building work at home. His condition deteriorated within hours, he developed severe rhabdomyolysis, multiple organ dysfunction syndrome, disseminated intravascular coagulopathy and died, despite early treatment. Discussion: A great index of suspicion for severe necrotizing soft tissue infections is necessary in patients on tocilizumab or other biologic immunosuppressive agents. The possible mechanisms in this setting include lowering CRP involved in innate immune responses, decrement of neutrophil count and function, increasing iron availability for infection, as well as high expression of vimentin, the streptococcal binding protein, by regenerating muscle fibers after trauma. Diarrhea due to endotoxins and flu-like symptoms may be early and sometimes they may be the only presenting signs of severe group A streptococcal infection in patients with blunt trauma on biologics. Low initial CRP and white blood cell count may be misleading. A rapid streptococcal strip test may help anticipate and possibly prevent a deleterious evolution in such patients. Conclusion: Biologics may modify the clinical presentation of NF, the LRINEC score, and the pathology decision algorithm. A great index of suspicion for severe soft tissue infections is required in patients on biologics with blunt trauma, especially when presenting with flu-like symptoms, diarrhea, or vomiting.