A 38-year-old man, allergic to penicillin, drinker of 80 grams of alcohol/day and obese, came to the Emergency Department of our Hospital presenting with oedema of the lower limbs, abdominal distension and fever of two days' evolution. He also reported severe asthenia for several weeks accompanied by nausea, vomiting and diarrhoea for the last 7 days. Physical examination revealed a temperature of 37.5ºC, abdominal ascites and oedema in both lower limbs, mainly on the right, associated with erythema, petechiae and ecchymosis. No other pathological findings were observed on examination.
The following results were obtained in the admission analysis: haemoglobin 8.3 g/dl; haematocrit: 23.3%; leukocytes 20,420 per µl (neutrophils 91.5%); platelets 119,000 per µl; D-dimers D3, D3, D3, D3, D3, D3, D3, D3, D3, D3, D3, D3, D3, D3. 000 per µl; Dimeros D 14.080 ng/dl; Urea: 178 mg/dl; Creatinine 9 mg/dl; Na 124 mEq/l; K 3,9 mEq/l; Total proteins 5,6 gr/dl, LDH 559 UI/l; CPK 239 UI/l; GPT 35 UI/l; GOT 77 UI/l. Chest X-ray was normal and abdominal ultrasound and CT scan showed massive ascites, evidence of chronic liver disease and splenomegaly. With the clinical judgement of acute renal failure, in the context of a chronic hepatopathy of enolic origin and cellulitis in the lower extremity, he was admitted to the Nephrology Department. Treatment was started with diuretics (Furosemide) and empirical antibiotic therapy with Ciprofloxacin (1g/24 hours) after blood cultures were taken. Twenty-four hours after admission, the patient presented fever (38.4ºC) and worsening of the lesions on the right lower limb (MID), with increased pain, extension of the cellulitis and presence of blisters. Laboratory tests showed worsening renal function with plasma creatinine values of 10.60 mg/dl and urea 181 mg/dl, increased leukocytosis (35,340 per µl, neutrophils 96.8%) and coagulation alterations (prothrombin time of 28.8 seconds and activated partial thromboplastin time of 61.4 seconds). The blood culture performed on admission isolated Streptococcus Pyogenes, so intravenous antibiotherapy with Clindamycin and Gentamycin was started and he was admitted to the Intensive Care Unit (ICU) due to haemodynamic instability and rapid progression of the lesions on the lower limb visible in a few hours, with skin anaesthesia, large blisters up to the middle third of the thigh and scrotal involvement. He required invasive mechanical ventilation, vasoactive amines and continuous veno-venous haemofiltration and urgent surgery was indicated in which scrotal debridement, debridement of the fascia up to the root of the thigh and open supracondylar amputation were performed.

He had an unfavourable evolution with multiorgan failure (acute renal failure, coagulopathy and acute respiratory distress syndrome) and did not respond to haemodynamic support measures or antibiotic therapy and finally died 24 hours after surgery.