[Streptococcus-A preseptal necrotizing fasciitis: A series of 10 cases and management recommendations]

We observed a marked increase in cases of preseptal necrotizing fasciitis over the course of a single year. While only one case had been recorded between 2016 and 2021, nine additional cases were managed between 2022 and 2023 at Rennes University Hospital.

We conducted a retrospective study including all cases of preseptal necrotizing fasciitis managed at our institution between 2016 and 2024. Clinical, microbiological, surgical, and outcomes data were analyzed. A review of the literature was also performed to propose an appropriate management strategy for these infections.

Since 2016, ten cases were identified. All were caused by virulent strains of Streptococcus pyogenes (group A Streptococcus), with genotypes emm1, emm1.3, and emm82. The mean patient age was 41 years, and most patients had few or no risk factors. The marked increase in incidence observed in 2023 appears to correlate with the post-pandemic resurgence of invasive streptococcal infections. Fifty percent of patients initially treated with incision and drainage with packing required repeat surgery within 24hours due to clinical deterioration. Following dermal debridement, upper eyelid retraction threatening corneal integrity was observed by the end of the second week in all cases, necessitating management with full-thickness skin grafting.

Recent epidemiological changes suggest that any case of preseptal necrotizing fasciitis should be considered a potential invasive group A Streptococcus infection. This warrants modifications in clinical practice, including empirical antibiotic therapy with clindamycin, patient contact isolation, case investigation, and antibiotic prophylaxis for close contacts. The conservative debridement technique described in this article achieved infection control in 100% of cases while limiting surgical morbidity. Healing by secondary intention may be considered in rare cases where the dermis is preserved. Reconstruction with full-thickness skin grafting combined with temporary tarsorrhaphy on postoperative day 15 appears to provide the best functional and aesthetic outcomes while minimizing corneal complications.

This series highlights a recent shift in the epidemiology of preseptal necrotizing fasciitis, supporting the consideration of any new case as a potentially invasive and transmissible group A Streptococcus infection with significant public health implications. This situation calls for adaptation of clinical practices.