A Death From Necrotizing Wound Infection After Cesarean Section: Resurgence of Group A Streptococcal Puerperal Sepsis

Necrotizing wound infections are potentially lethal complications of surgeries, including cesarean deliveries. A 32-year-old female with obesity and hidradenitis suppurativa (HS) underwent uncomplicated cesarean section. Four days later, she developed abdominal pain and imaging showed ascites; she was treated with antibiotics. She progressed to septic shock and expired the following day from cardiopulmonary arrest. Hospital blood cultures grew no microorganisms. Autopsy revealed soft tissue purulence around the incision and copious purulent ascites without evidence of tubo-ovarian abscess, retained products of conception, or emboli. Microscopic examination of the tissues demonstrated inflammatory debris with neutrophils and gram-positive cocciform bacteria. Postmortem bacterial cultures had no growth. Paraffin blocks submitted to the Centers for Disease Control Infectious Disease Pathology Branch revealed Streptococcus pyogenes . Historically, group A streptococcus (GAS) was a major cause of peripartum mortality, and the prevalence of puerperal sepsis-associated deaths declined with antibiotic usage. Although the rates of mortality have remained stable in the United States, GAS has made a resurgence over recent decades. Additionally, there is some evidence in the literature of cutaneous bacterial biofilms associated with HS. Theoretically, this could have increased the risk of perioperative infection due to colonization or secondary infection of HS lesions.