EP1087 - Group A Streptococcus Pelvic Sepsis After Elective Hemorrhoidectomy: A Case Report

Purpose/Background: Group A Streptococcus (Streptococcus pyogenes) is a common pathogen in superficial skin infections, soft tissue infections, tonsillitis, and postpartum endometritis but can also cause rapidly progressive invasive diseases, including necrotizing soft tissue infections and toxic shock syndrome. Postoperative GAS infections following anorectal surgery are exceptionally uncommon with only one reported case in literature. Therefore, early detection and treatment is key to decreasing morbidity and mortality

Methods/Interventions: We describe a rare case of invasive GAS infection following routine anorectal surgery. A 46-year-old woman with a history of chronic anal fissure and internal hemorrhoids underwent elective rectal examination under anesthesia with fissurectomy, hemorrhoidectomy, and botulinum toxin injection. The procedure was uncomplicated, and she was discharged the same day. On postoperative day (POD) 5, she presented with severe bilateral hip and thigh pain, urinary retention, constipation, and tachycardia. Laboratory testing revealed acute kidney injury. CT abdomen/pelvis showed distal rectosigmoid wall thickening concerning for pelvic sepsis. Broad-spectrum intravenous antibiotics were initiated, and repeat examination under anesthesia revealed purulent drainage from the posterior hemorrhoidectomy site, which was surgically drained and cultured.

Results/Outcomes: Wound and blood cultures grew Streptococcus pyogenes (GAS) and Enterobacter cloacae. Antibiotics were escalated to vancomycin, clindamycin, and levofloxacin for broad coverage and toxin suppression. Nephrology was consulted for acute kidney injury, which resolved with intravenous fluid resuscitation and supportive management by POD2. Intravenous immunoglobulin (IVIG) was administered for toxin-mediated sepsis. Her hemodynamics remained stable without vasopressor support, and her pain and tachycardia gradually improved. During recovery, she developed abdominal distention and thigh discomfort. Repeat imaging demonstrated resolving pelvic inflammation with postoperative ileus and mild thigh cellulitis. Both were managed conservatively with bowel rest, fluids, and gradual advancement of diet. Over the ensuing days, leukocytosis and inflammatory markers normalized, renal function returned to baseline, and bowel function resumed. She transitioned to oral linezolid, levofloxacin, and metronidazole to complete a 7-day antibiotic course. The patient was discharged on POD7 in stable condition. At follow-up, she remained asymptomatic with complete recovery and no recurrence of infection.

Conclusion/Discussion: This case highlights a rare but severe complication of hemorrhoidectomy due to Group A Streptococcus pelvic sepsis. Rapid clinical deterioration following minor anorectal surgery should raise suspicion for invasive GAS infection. Prompt surgical drainage, broad-spectrum antibiotics, and consideration of adjunctive IVIG are key components of management. Awareness of this rare entity can facilitate early diagnosis and improve outcomes in postoperative anorectal patients.