Severe upper limb soft tissue infection with compartment syndrome following a scratch injury: a case report

Phlegmon is a severe skin and soft tissue infection (SSTI) that can escalate rapidly if not promptly recognized and treated. Its early presentation may appear deceptively mild, potentially delaying recognition of its severity. Without timely intervention, phlegmon can extend into deeper tissues and result in life-threatening systemic complications. Although SSTIs are common, progression from a seemingly minor scratch injury to a fulminant upper extremity infection complicated by compartment syndrome and multiorgan failure is uncommon. This case is reported to highlight the potential severity of such presentations and the importance of early recognition and intervention.

We present the case of a 58-year-old German female teacher who developed a severe left upper extremity SSTI following a minor scratch injury sustained from a student. Despite initial conservative management with antibiotic therapy, the condition progressed to severe phlegmon with compartment syndrome, culminating in sepsis and multiorgan failure characterized by acute renal failure, disseminated intravascular coagulation (DIC), and early liver failure. Urgent surgical intervention was required, including fasciotomy, surgical debridement, and multiple revision procedures. Microbiological cultures initially identified Streptococcus pyogenes (Group A). During the later course of treatment, Pseudomonas aeruginosa was detected in revision samples. Empirical intravenous antibiotic therapy with Meropenem was initiated and subsequently adjusted to Ampicillin/Sulbactam according to microbiological findings. The patient required hemodialysis because of acute renal failure but gradually recovered, allowing discontinuation of dialysis. At follow-up, the infection had resolved and the skin grafts demonstrated satisfactory healing; however, significant functional deficits persisted despite intensive rehabilitation.

This case underscores the critical importance of early diagnosis and aggressive multidisciplinary management in preventing severe complications associated with SSTIs. Furthermore, it highlights that seemingly minor skin injuries may progress to compartment syndrome and life-threatening systemic complications. Early recognition, prompt surgical intervention, and coordinated multidisciplinary care were essential for successful infection control and limb preservation.