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

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Τίτλος: Severe upper limb soft tissue infection with compartment syndrome following a scratch injury: a case report.
Συγγραφείς: Blümke A; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. alexander.bluemke@umm.de., Brunnemer S; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany., Weil F; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; BG Klinik Ludwigshafen, Department of Trauma and Orthopedic Surgery, Heidelberg University, Ludwigshafen, Germany., Pinheiro J; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany., Bludau F; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany., Hackl M; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany., Gravius S; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; BG Klinik Ludwigshafen, Department of Trauma and Orthopedic Surgery, Heidelberg University, Ludwigshafen, Germany., Darwich A; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
Πηγή: Journal of medical case reports [J Med Case Rep] 2026 Sep 30; Vol. 20 (1). Date of Electronic Publication: 2026 Sep 30.
Τύπος έκδοσης: Journal Article; Case Reports
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: BioMed Central Country of Publication: England NLM ID: 101293382 Publication Model: Electronic Cited Medium: Internet ISSN: 1752-1947 (Electronic) Linking ISSN: 17521947 NLM ISO Abbreviation: J Med Case Rep Subsets: MEDLINE
Imprint Name(s): Original Publication: [London] : BioMed Central, [2007-
Ιατρικοί όροι (MeSH): Compartment Syndromes*/therapy , Compartment Syndromes*/microbiology , Compartment Syndromes*/etiology , Soft Tissue Infections*/microbiology , Soft Tissue Infections*/therapy , Soft Tissue Infections*/complications , Soft Tissue Infections*/diagnosis , Cellulitis*/microbiology , Cellulitis*/therapy , Upper Extremity*/injuries , Pseudomonas Infections*/complications , Pseudomonas Infections*/drug therapy , Pseudomonas Infections*/diagnosis , Streptococcal Infections*, Anti-Bacterial Agents/therapeutic use ; Multiple Organ Failure/etiology ; Streptococcus pyogenes/isolation & purification ; Meropenem/therapeutic use ; Pseudomonas aeruginosa/isolation & purification ; Humans ; Female ; Middle Aged ; Debridement ; Treatment Outcome
Περίληψη: Background: 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.
Case Presentation: 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.
Conclusion: 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.
(© 2026. The Author(s).)
Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was waived for this case report as the presented case was considered a part of the usual patient care. Verbal and informed written consent was obtained from the patient to use her clinical data and images to publish her case report; no identification of the patient’s identity is present in the manuscript or the images. The authors confirm that this work followed The Code of Ethics of the World Medical Association (Declaration of Helsinki). Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests: The authors declare that they have no competing interests.
References: Burillo A, Pulido-Pérez A, Bouza E. Current challenges in acute bacterial skin infection management. Curr Opin Infect Dis. 2024;37(2):71–9. https://doi.org/10.1097/QCO.0000000000000989 . (PMID: 10.1097/QCO.000000000000098938179868)
Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–37. https://doi.org/10.1001/JAMA.2016.8825 . (PMID: 10.1001/JAMA.2016.882527434444)
Kaye KS, Petty LA, Shorr AF, Zilberberg MD. Current epidemiology, etiology, and burden of acute skin infections in the United States. Clin Infect Dis. 2019;68(Supplement_3):S193–9. https://doi.org/10.1093/CID/CIZ002 . (PMID: 10.1093/CID/CIZ002309571656452002)
Urbina T. Antibiotics in necrotizing soft tissue infections. Antibiotics (Basel). 2021;10(9): 1104. https://doi.org/10.3390/ANTIBIOTICS10091104 . (PMID: 10.3390/ANTIBIOTICS10091104345726868466904)
Boettler MA, Kaffenberger BH, Chung CG. Cellulitis: a review of current practice guidelines and differentiation from pseudocellulitis. Am J Clin Dermatol. 2022;23(2):153–65. https://doi.org/10.1007/S40257-021-00659-8 . (PMID: 10.1007/S40257-021-00659-834902109)
Zervos MJ. Epidemiology and outcomes of complicated skin and soft tissue infections in hospitalized patients. J Clin Microbiol. 2012. https://doi.org/10.1128/JCM.05817-11/ASSET/8C849438-53D7-4CCC-A4A8-B47E2B8198D7/ASSETS/GRAPHIC/ZJM9990913360001.JPEG . (PMID: 10.1128/JCM.05817-11/ASSET/8C849438-53D7-4CCC-A4A8-B47E2B8198D7/ASSETS/GRAPHIC/ZJM9990913360001.JPEG223379803347104)
Marwick C. Severity assessment of skin and soft tissue infections: cohort study of management and outcomes for hospitalized patients. J Antimicrob Chemother. 2011;66(2):387–97. https://doi.org/10.1093/JAC/DKQ362 . (PMID: 10.1093/JAC/DKQ36220926396)
Sartelli M. World society of emergency surgery (WSES) guidelines for management of skin and soft tissue infections. World J Emerg Surg. 2014. https://doi.org/10.1186/1749-7922-9-57/TABLES/1 . (PMID: 10.1186/1749-7922-9-57/TABLES/1254226714242587)
Contributed Indexing: Keywords: Case report; Compartment syndrome; Necrosectomy; Phlegmon; SSTI
Substance Nomenclature: 0 (Anti-Bacterial Agents)
FV9J3JU8B1 (Meropenem)
Entry Date(s): Date Created: 20261001 Date Completed: 20261001 Latest Revision: 20261001
Update Code: 20261001
DOI: 10.1186/s13256-026-06651-2
PMID: 42816883
Βάση Δεδομένων: MEDLINE
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  Data: Severe upper limb soft tissue infection with compartment syndrome following a scratch injury: a case report.
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  Data: <searchLink fieldCode="AU" term="%22Blümke+A%22">Blümke A</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. alexander.bluemke@umm.de.<br /><searchLink fieldCode="AU" term="%22Brunnemer+S%22">Brunnemer S</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.<br /><searchLink fieldCode="AU" term="%22Weil+F%22">Weil F</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; BG Klinik Ludwigshafen, Department of Trauma and Orthopedic Surgery, Heidelberg University, Ludwigshafen, Germany.<br /><searchLink fieldCode="AU" term="%22Pinheiro+J%22">Pinheiro J</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.<br /><searchLink fieldCode="AU" term="%22Bludau+F%22">Bludau F</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.<br /><searchLink fieldCode="AU" term="%22Hackl+M%22">Hackl M</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.<br /><searchLink fieldCode="AU" term="%22Gravius+S%22">Gravius S</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.; BG Klinik Ludwigshafen, Department of Trauma and Orthopedic Surgery, Heidelberg University, Ludwigshafen, Germany.<br /><searchLink fieldCode="AU" term="%22Darwich+A%22">Darwich A</searchLink>; Department of Orthopedics and Trauma Surgery, Universitätsklinikum Heidelberg - UK Mannheim GmbH, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: 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.<br />Case Presentation: 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.<br />Conclusion: 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.<br /> (© 2026. The Author(s).)
– Name: Abstract
  Label: Competing Interests
  Group: Ab
  Data: Declarations. Ethics approval and consent to participate: Ethical approval was waived for this case report as the presented case was considered a part of the usual patient care. Verbal and informed written consent was obtained from the patient to use her clinical data and images to publish her case report; no identification of the patient’s identity is present in the manuscript or the images. The authors confirm that this work followed The Code of Ethics of the World Medical Association (Declaration of Helsinki). Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests: The authors declare that they have no competing interests.
– Name: Ref
  Label: References
  Group: RefInfo
  Data: Burillo A, Pulido-Pérez A, Bouza E. Current challenges in acute bacterial skin infection management. Curr Opin Infect Dis. 2024;37(2):71–9. https://doi.org/10.1097/QCO.0000000000000989 . (PMID: <searchLink fieldCode="PM" term="%2210%2E1097%2FQCO%2E000000000000098938179868%22">10.1097/QCO.000000000000098938179868)</searchLink><br />Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–37. https://doi.org/10.1001/JAMA.2016.8825 . (PMID: <searchLink fieldCode="PM" term="%2210%2E1001%2FJAMA%2E2016%2E882527434444%22">10.1001/JAMA.2016.882527434444)</searchLink><br />Kaye KS, Petty LA, Shorr AF, Zilberberg MD. Current epidemiology, etiology, and burden of acute skin infections in the United States. Clin Infect Dis. 2019;68(Supplement_3):S193–9. https://doi.org/10.1093/CID/CIZ002 . (PMID: <searchLink fieldCode="PM" term="%2210%2E1093%2FCID%2FCIZ002309571656452002%22">10.1093/CID/CIZ002309571656452002)</searchLink><br />Urbina T. Antibiotics in necrotizing soft tissue infections. Antibiotics (Basel). 2021;10(9): 1104. https://doi.org/10.3390/ANTIBIOTICS10091104 . (PMID: <searchLink fieldCode="PM" term="%2210%2E3390%2FANTIBIOTICS10091104345726868466904%22">10.3390/ANTIBIOTICS10091104345726868466904)</searchLink><br />Boettler MA, Kaffenberger BH, Chung CG. Cellulitis: a review of current practice guidelines and differentiation from pseudocellulitis. Am J Clin Dermatol. 2022;23(2):153–65. https://doi.org/10.1007/S40257-021-00659-8 . (PMID: <searchLink fieldCode="PM" term="%2210%2E1007%2FS40257-021-00659-834902109%22">10.1007/S40257-021-00659-834902109)</searchLink><br />Zervos MJ. Epidemiology and outcomes of complicated skin and soft tissue infections in hospitalized patients. J Clin Microbiol. 2012. https://doi.org/10.1128/JCM.05817-11/ASSET/8C849438-53D7-4CCC-A4A8-B47E2B8198D7/ASSETS/GRAPHIC/ZJM9990913360001.JPEG . (PMID: <searchLink fieldCode="PM" term="%2210%2E1128%2FJCM%2E05817-11%2FASSET%2F8C849438-53D7-4CCC-A4A8-B47E2B8198D7%2FASSETS%2FGRAPHIC%2FZJM9990913360001%2EJPEG223379803347104%22">10.1128/JCM.05817-11/ASSET/8C849438-53D7-4CCC-A4A8-B47E2B8198D7/ASSETS/GRAPHIC/ZJM9990913360001.JPEG223379803347104)</searchLink><br />Marwick C. Severity assessment of skin and soft tissue infections: cohort study of management and outcomes for hospitalized patients. J Antimicrob Chemother. 2011;66(2):387–97. https://doi.org/10.1093/JAC/DKQ362 . (PMID: <searchLink fieldCode="PM" term="%2210%2E1093%2FJAC%2FDKQ36220926396%22">10.1093/JAC/DKQ36220926396)</searchLink><br />Sartelli M. World society of emergency surgery (WSES) guidelines for management of skin and soft tissue infections. World J Emerg Surg. 2014. https://doi.org/10.1186/1749-7922-9-57/TABLES/1 . (PMID: <searchLink fieldCode="PM" term="%2210%2E1186%2F1749-7922-9-57%2FTABLES%2F1254226714242587%22">10.1186/1749-7922-9-57/TABLES/1254226714242587)</searchLink>
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  Data: <i>Keywords: </i>Case report; Compartment syndrome; Necrosectomy; Phlegmon; SSTI
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      – TitleFull: Severe upper limb soft tissue infection with compartment syndrome following a scratch injury: a case report.
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            NameFull: Blümke A
      – PersonEntity:
          Name:
            NameFull: Brunnemer S
      – PersonEntity:
          Name:
            NameFull: Weil F
      – PersonEntity:
          Name:
            NameFull: Pinheiro J
      – PersonEntity:
          Name:
            NameFull: Bludau F
      – PersonEntity:
          Name:
            NameFull: Hackl M
      – PersonEntity:
          Name:
            NameFull: Gravius S
      – PersonEntity:
          Name:
            NameFull: Darwich A
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 30
              M: 09
              Text: 2026 Sep 30
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-electronic
              Value: 1752-1947
          Numbering:
            – Type: volume
              Value: 20
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Journal of medical case reports
              Type: main
ResultId 1