Fulminant septic shock from clinically occult deep soft tissue infection in chronic lymphedema: A clinicopathological correlation

Chronic lymphedema is a well-recognized risk factor for recurrent cellulitis. However, deep soft tissue infections in lymphedematous limbs may present without classical cutaneous signs, leading to delayed diagnosis and rapid clinical deterioration. We report a 35-year-old woman with chronic filarial lymphedema and prior recurrent cellulitis who presented with a three-day history of fever, myalgia, and arthralgia without localizing symptoms. Initial examination revealed no evidence of cellulitis. She rapidly developed severe neutropenia, thrombocytopenia, acute kidney injury, severe metabolic acidosis, followed by refractory shock and acute hypoxic respiratory failure. Despite early broad-spectrum antibiotics, vasopressor support, and intensive care management, she deteriorated and died within 24 hours of admission. Blood cultures remained negative. Post-mortem examination demonstrated multiorgan failure consistent with septic shock and revealed deep subcutaneous cellulitis without superficial skin inflammation.This case highlights that chronic lymphedema may predispose to clinically occult deep soft tissue infection, which can progress rapidly to fulminant septic shock in the absence of overt cutaneous findings. A high index of suspicion is essential in patients with systemic inflammatory features, and early empiric antimicrobial therapy should be considered even when classical signs of cellulitis are absent. • Chronic lymphedema can harbor occult deep soft tissue infection. • Absence of skin signs may delay diagnosis of severe infection. • The illness progressed rapidly to fulminant septic shock. • Severe neutropenia may be an early clue to systemic infection. • Autopsy revealed deep cellulitis without surface inflammation. • Lymphedema can mask classical features of cellulitis. • Early empiric broad-spectrum therapy is essential. • MRSA coverage should be considered in rapidly worsening cases