Abstract / Summary
Abstract Background: A furuncle of the gluteal region, aggravated by scratching in a patient with poorly controlled type 2 diabetes, may progress to necrotizing soft-tissue infection, septic shock, and life-threatening immune dysregulation. We report an unusual case in which a seemingly trivial furuncle precipitated septic shock with secondary hemophagocytic lymphohistiocytosis (HLH) and multi-organ dysfunction, complicated by an 18 x 8 cm full-thickness gluteal wound adjacent to the anus, yet healed completely without skin grafting. Case presentation: A 53-year-old Han Chinese man with a one-month history of type 2 diabetes and a 15-year history of hypertension scratched a right gluteal furuncle on September 13, 2024. Within days he developed septic shock with profound pancytopenia (white blood cell count 1.25 x 10^9/L, absolute neutrophil count 0.13, platelets 11 x 10^9/L, hemoglobin 89 g/L), peak procalcitonin 25.3 ng/mL and interleukin-6 > 5000 pg/mL, and cardiac, hepatic, and renal dysfunction. He fulfilled six of seven applicable HLH-2004 criteria (fever, splenomegaly, cytopenias, hypertriglyceridemia with hypofibrinogenemia, elevated soluble interleukin-2 receptor at 3027 U/mL, and ferritin > 500 ng/mL; bone marrow showed no hemophagocytosis). Targeted gene sequencing (tGS) of wound secretions identified methicillin-resistant Staphylococcus aureus, Klebsiella pneumoniae, Stenotrophomonas maltophilia, Enterococcus faecium, Pseudomonas aeruginosa, and Candida species. After resuscitation, broad-spectrum antimicrobials, granulocyte colony-stimulating factor, and dexamethasone for HLH, surgical debridement on day 20 disclosed an 18 x 8 cm full-thickness necrotic wound with honeycomb-like fat necrosis and copious pus; vacuum-assisted closure (VSD, 15 x 5 cm foam) drained substantial pus but could not cover the entire wound. Subsequent twice-daily debridement with topical zinc sulfadiazine cream, then an antimicrobial ointment and a chlorhexidine-based antimicrobial ointment, progressively yielded granulation tissue, marginal epithelial advancement, and wound contraction. The patient was discharged on day 53 with a 15 x 5 cm contracting wound and continued daily self-dressing changes. Serial photography documented progressive re-epithelialization; the patient reported complete healing by March 2025, achieving near-scarless second-intention healing without skin grafting. At 16-month follow-up (June 2026), the previously massive wound had healed by spontaneous epithelialization without skin grafting, leaving an elongated atrophic scar that was flat, without hypertrophic elevation, depression, ulceration, sinus tract, erythema, or exudate, with hypopigmentation over the scar and hyperpigmentation of the surrounding skin, and without scar contracture.