Sepsis can be the result of single or multiple factors and sources of infection. Oral sources of sepsis and systemic infection are not commonly considered as the first potential source of infection when evaluating a septic patient. Oral infections of odontogenic or periodontal origin are frequently associated with localized or diffuse cellulitis of the head and neck region. 1 The patient’s health status and complicating problems, such as an immunocompromising condition, can further reduce the immune response for controlling chronic sources of infection. This in turn can lead to acute manifestations such as cellulitis, sepsis, or necrotizing fasciitis. Necrotizing fasciitis is caused by a polymicrobial or mixed aerobic-anaerobic infection from a variety of sources, including Streptococcus pyogenes .
A 57-year-old woman with a history of major depressive disorder, paroxysmal atrial fibrillation, and opioid dependence that was in remission for more than 3 years was brought to the ED by a family member after the patient developed confusion and lethargy. She was primarily experiencing right breast pain and swelling. The breast pain was associated with high fevers, nausea, vomiting, and chills.
On examination, the patient’s vital signs were: blood pressure (BP), 109/58 mm Hg; heart rate, 160 beats/min; respiratory rate, 22 breaths/min; and temperature, 104°F. Laboratory evaluation was significant for a white blood cell count (WBC) of 8.7 x 103. There was a noted skin abrasion on the patient’s right hand. She was lethargic and confused. Blood cultures were positive for S pyogenes, and a swab of the right breast was negative for bacterial growth.
The patient was admitted to the medical intensive care unit (MICU) and placed on two vasopressors for control of low BP and assistance with low urine output. After a 6-L fluid resuscitation, the patient was started on vancomycin and piperacillin/tazobactam for possible cellulitis causing sepsis. An echocardiogram was negative for endocarditis. The patient continued to decline the following day with continuing tachycardia and tachypnea with hypotension and was intubated. Pulmonology services was consulted for possible acute respiratory distress syndrome secondary to sepsis; general surgery services was consulted for possible necrotizing fasciitis of the chest wall; and cardiology services was consulted for low-cardiac output.