TABLE 2:

Early diagnostic clues for severe invasive group A streptococcal infections^*

Clinical

Influenza-like symptoms such as fever, aches, pains and chills

Severe pain

Rapid breathing, signs of pleural effusion

Secondary fever following varicella infection suggests invasive group A streptococcus disease

Laboratory

Normal or elevated white blood cell count, with marked ‘left shift’ (high number of immature neutrophils)

Prolonged prothrombin time and partial prothrombin time

Low platelet count

Low albumin

Low calcium

High creatinine phosphokinase (CPK)†

Magnetic resonance imaging (MRI) (or computed tomography scan or ultrasound if MRI not available). This should not delay surgical consultation

^*None of the signs and laboratory features are specific, and all the features noted in Table 1 can occur at any time.

^†CPK elevation may be a sign of early necrotizing fasciitis with muscle involvement (myositis), but fasciitis may still occur in the presence of a normal CPK if there is no muscle involvement