Streptococcal toxic shock syndrome in the intensive care unit

Managing toxic shock syndrome in immunosuppressed patient after liver transplantation from trauma to triumph: A case report

BACKGROUND

Streptococcal toxic shock syndrome (STSS), caused by group A Streptococcus (Streptococcus pyogenes), is characterized by shock and multiorgan failure and is associated with a high mortality rate. Organ transplant recipients are especially vulnerable due to immunosuppressive therapy. Although critical for graft survival, immunosuppression increases susceptibility to infections, the leading cause of morbidity and mortality early after liver transplantation.

CASE SUMMARY

A 69-year-old female on dual immunosuppressive regimen with mycophenolate mofetil and tacrolimus due to liver transplantation in 2010 and chronic kidney disease presented to the emergency department after tripping at home and injuring her neck with a wooden splinter from a chair. She developed progressive neck swelling and erythema with a diffuse maculopapular rash. Contrast-enhanced computed tomography scan showed a multiloculated neck abscess (59 mm × 32 mm × 85 mm). Her leucocyte count was 22.4 × 10⁹/L, C-reactive protein 327.4 mg/L, and creatinine 233 μmol/L. Microbiological analysis tested positive for group A Streptococcus, suggesting diagnosis of STSS. She developed hypotension, dyspnea and fever prompting an urgent surgical drainage. Mycophenolate mofetil was discontinued, tacrolimus was reduced and was treated with cephazolin and clindamycin. Her skin rash slowly resolved, C-reactive protein decreased to 53.0 mg/L and kidney function improved. A computed tomography scan confirmed resolution and showed no new abscess formation. After two years of follow-up, she is unremarkable.

CONCLUSION

STSS in organ transplant recipients demands rapid managing of infections while minimizing the risk of graft rejection.

Unexpected sepsis due to Group A beta haemolytic Streptococcus following total thyroidectomy

Thyroidectomy is a clean surgery, with the presentation of postoperative infections being uncommon and an exceedingly rare incidence of postoperative sepsis.A female patient in her early 80s became acutely unwell following total thyroidectomy within the immediate postoperative period, with features suggestive of sepsis. She developed new-onset atrial fibrillation (AF), and her care was escalated to the intensive treatment unit (ITU) on the same day postoperatively. While in the ITU, she deteriorated with multiorgan failure (MOF). There was no evidence of a surgical site infection (SSI).Beta haemolytic lancefield Group A Streptococcus (GAS) was isolated from positive blood cultures, confirming the diagnosis of streptococcal toxic shock syndrome (TSS). She was treated with targeted antibiotics and intravenous immunoglobulin (IG) and received supportive care for MOF.In our case, sepsis developed in the immediate postoperative period of total thyroidectomy. A high index of suspicion and prompt treatment are required to minimise the risks of morbidity and mortality.

Toxic Shock Syndrome due to Streptococcus Pyogenes: Case Report

BACKGROUND

Toxic shock syndrome (TSS) is one of the most devastating clinical manifestations of Streptococcus pyogenes (also known as Group A Streptococci or GAS), characterized by an overwhelming production of toxins. The incidence of TSS is increasing worldwide, and the mortality rate remains unacceptably high. Due to the rapid progression of infection, rapid diagnosis is crucial, as early initiation of aggressive supportive measures, along with antibiotics, source control, immunoglobulin, and steroids, can improve patient outcomes. IgM- and IgA-enriched immunoglobulins represents a new therapeutic option, as highlighted in the case reported here.

CASE REPORT

A 66-year-old man was admitted for cellulitis of the right arm with shock, disseminated intravascular coagulation (DIC), renal and hepatic compromise, suggestive of toxic shock syndrome (TSS). Blood cultures revealed S. pyogenes, confirming the diagnosis. The patient was treated with combination antibiotic therapy (clindamycin, piperacillin/tazobactam), steroids and enriched immunoglobulins in addition to vasopressor and high flow oxygen. He was discharged home with complete recovery after 1 month. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In the emergency department, the primary goals of management of TSS include aggressive resuscitation, prompt administration of appropriate antibiotics, source control if feasible, and early intensive care unit admission.

Streptococcal Toxic Shock Syndrome: A Case Series Emphasizing the Urgency of Recognition and Tailored Treatment

BACKGROUND

Streptococcal toxic shock syndrome (TSS) is a rare but lethal condition associated with Streptococcus Pyogenes Group A (GAS). With rising incidence and high mortality, timely recognition and management are crucial. This case series presents two adult TSS cases caused by invasive GAS, highlighting the importance of early identification and multidisciplinary management.

CASE PRESENTATIONS

The first case involves a 42-year-old male who presented with fever, dizziness, and a tender, erythematous olecranon following an elbow laceration. Despite negative imaging for necrotizing fasciitis, a positive throat swab for GAS prompted immediate broad-spectrum antibiotics and aggressive resuscitation. Clindamycin and intravenous immunoglobulin were administered. The patient developed TSS and acute kidney injury, requiring intensive care and hemodialysis. The second case features a previously healthy 43-year-old female presenting with systemic symptoms and a rash, without trauma history. Positive GAS blood cultures confirmed TSS, leading to similar management and subsequent renal complications requiring hemodialysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases highlight the evolving epidemiology of invasive GAS infections and the associated risk of TSS. Early identification and appropriate tailored treatment are essential to reduce morbidity and mortality, especially given the recent surge in invasive GAS. Clinical vigilance for skin changes and thorough laboratory investigations, including non-sterile site cultures, are critical. Early identification enables the use of adjunctive treatments like clindamycin and IVIG, and facilitates appropriate de-escalation of antibiotics. Prompt consultation with infectious disease, intensive care, and surgical teams is necessary to ensure optimal treatment.

Streptococcal Toxic Shock Syndrome: Diagnostic and Therapeutic Approaches Incorporating Point-of-Care Antigen Testing-Case Series

BACKGROUND

Streptococcal toxic shock syndrome (STSS) is a serious and potentially fatal complication of invasive Streptococcus pyogenes (Group A Streptococcus, GAS) infection, often stemming from severe soft tissue infections. While uncommon, tonsillitis can also lead to STSS, with lethality rates reported as high as 70%.

METHODS

We present three cases of patients diagnosed with tonsillitis who developed STSS. Point-of-care testing for GAS antigens was utilized to facilitate rapid diagnosis.

RESULTS

In all three cases, the characteristic clinical presentations, including scarlatiniform rash, strawberry tongue, and signs of shock with multi-organ dysfunction, were observed. Microbiological evidence confirmed ongoing GAS infections, and point-of-care testing for GAS antigens assisted in the diagnosis of tonsillitis in conjunction with STSS, enabling timely treatment interventions.

CONCLUSIONS

Rapid diagnosis is crucial for the optimal management of STSS. The point-of-care testing for GAS may be useful for diagnosing STSS associated with tonsillitis.

Treatment of toxic shock in children

Toxic shock syndrome (TSS) is a life-threatening complication of infection typically caused by one of two bacterial species: Staphylococcus aureus and Streptococcus pyogenes The outcomes in children with TSS can be devastating. Careful consideration of TSS is required as a potential differential diagnosis of children presenting with sepsis or severe illness associated with fever and rash.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

A Rare Case of Streptococcal Toxic Shock Syndrome Associated With Pneumonia

Streptococcal toxic shock syndrome (STSS) is a rapidly progressing and life-threatening illness caused by group A Streptococcus (GAS), typically associated with invasive infections such as necrotizing fasciitis and characterized by high mortality rates. Although GAS is an uncommon cause of community-acquired pneumonia (CAP), it can lead to severe illness in both healthy individuals and those with comorbidities. We report a case of STSS with pneumonia in a previously healthy 69-year-old female who presented with severe respiratory distress and shock without skin lesions. Despite the rapid progression typical of STSS, the patient showed remarkable clinical improvement with tazobactam/piperacillin and azithromycin, without the administration of clindamycin. This study challenges the conventional approach that emphasizes clindamycin due to its antitoxin effects, highlighting the importance of individualized therapeutic decisions. This case underscores the necessity of considering STSS in the differential diagnosis of severe respiratory infections in adults, even in the absence of skin manifestations. Further research is needed to clarify the role of antitoxin therapies and to establish evidence-based guidelines for managing STSS, particularly in cases presenting with pneumonia without skin involvement.

Multisystem organ failure secondary to group a streptococcal sepsis in a non-pregnant female

In multisystem organ failure, clinicians should consider gynecologic origin for source of infection. Obtaining early tissue samples can be a critical component in source control.

Streptococcal toxic shock syndrome in the immediate postpartum period

In the puerperal phase, streptococcal toxic shock syndrome is a relatively uncommon occurrence. However, there has been a rise in the prevalence of more aggressive strains of Group A Streptococcus (GAS), leading to significant maternal morbidity and mortality. In this report, we present a case of a postpartum patient who developed streptococcal toxic shock syndrome with substantial inflammation shortly after delivery. The patient presented on the second postpartum day with hypotension, high fever, hypogastric tenderness and anaemia. After timely workup and appropriate antibiotic therapy, the patient fully recovered. Culture studies confirmed Gram-positive septicaemia with the presence of Streptococcus pyogenes in both the patient's blood and a previously inserted intrauterine device (IUD). This case underscores the importance of maintaining a high index of suspicion for GAS as the cause of puerperal infections despite its rarity. This results in prompt administration of antibiotics and source control, preventing consequences and avoiding mortality.

Toxin inhibition: Examining tetracyclines, clindamycin, and linezolid

PURPOSE

The purpose of this review is to discuss the role of toxin inhibition in select infections and to provide recommendations for appropriate antimicrobial selection when toxin inhibition is indicated.

SUMMARY

For select organisms, specifically Clostridioides difficile, Staphylococcus aureus, and Streptococcus pyogenes, toxin production plays an integral role in overall disease pathogenesis and progression. Some expert recommendations include utilization of an antimicrobial with toxin inhibition properties as primary or adjunctive therapy for certain infections due to these organisms, but evolving data have made the choice of antitoxin agent less clear. Clindamycin has been the long-standing standard of care agent for toxin inhibition in necrotizing S. aureus and S. pyogenes infections, but linezolid shows promise as an alternative either in the setting of drug shortages or simply when clindamycin is not optimal, while tetracyclines require further study for this indication. The role for adjunctive toxin inhibition in C. difficile infection (CDI) is less defined, as current first-line therapies already have antitoxin properties.

CONCLUSION

Toxin inhibition plays a key role in successful management of patients with infections due to toxin-producing organisms. Adjunctive therapy with a tetracycline could be considered in severe, fulminant CDI, but the associated benefit is variable. The benefit of antitoxin treatment for necrotizing S. aureus and S. pyogenes has been more consistently documented. Recent studies support linezolid as an alternative to clindamycin as an adjunctive S. aureus treatment or as monotherapy when appropriate.

Trends in the growing impact of group A Streptococcus infection on public health after COVID-19 pandemic: a multicentral observational study in Okayama, Japan

PURPOSE

Following the COVID-19 pandemic, group A Streptococcus (GAS) infection has been surging worldwide. We aimed to compare the disease burden between notified cases of streptococcal toxic shock syndrome (STSS) and unreported GAS infections.

METHODS

This is a multicentral observational study, retrospectively performed at seven hospitals in Okayama prefecture in Japan from January 2022, to June 2024. Clinical and microbiological data of patients with positive cultures of GAS were collected from the medical records. Primary outcomes were defined as rates of surgical procedures, intensive care unit (ICU) admission, and in-hospital mortality, which were compared among patients with locally-defined STSS, invasive GAS (iGAS), and non-iGAS infection.

RESULTS

GAS was detected in 181 patients, with 154 active cases of GAS infection. The number of patients with GAS infection surged in late 2023. The most common source of infection was skin and soft tissue infections, accounting for 83 cases, including 15 cases of necrotizing fasciitis, and 12 cases (7.8%) were notified to public health authorities as STSS. Among the 25 unreported iGAS cases, 9 (36.0%) underwent surgical intervention, and 4 patients (16.0%) required ICU admission. The mortality rates in the unreported iGAS cases were comparable to those observed in the notified STSS.

CONCLUSIONS

We highlighted that the number of iGAS infections was twofold higher than that of notified STSS, with comparable mortality rate between these groups, indicating substantial underestimation of the true burden of iGAS. This epidemiological investigation has significant implications for enhancing infectious disease surveillance frameworks and public health policy development.

Streptococcal Toxic Shock Syndrome with Multiple Cerebral Infarctions Caused by Streptococcus dysgalactiae subsp. equisimilis: An Autopsy Case Report

We herein report an autopsy case of streptococcal toxic shock syndrome (STSS) with disseminated intravascular coagulation and multiple cerebral infarctions induced by Streptococcus dysgalactiae subsp. equisimilis in an 84-year-old male. Pathological examination revealed sepsis with hemophagocytosis in the reticular system and intravascular bacteria in multiple organs, originating from bacterial necrotizing fasciitis of the lower extremities. The brain MRI findings showed a diffusion weighted imaging-fluid-attenuated inversion-recovery mismatch, whereas the pathology was almost normal, thus supporting a hyperacute phase of cerebral infarction. The findings in this case help to elucidate the pathogenesis of STSS and develop appropriate treatment strategies.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

An Autopsy Case of Rapidly Fulminant Group A Streptococcus Infection in a Previously Healthy 67-Year-Old Woman

Streptococcus pyogenes, also known as group A Streptococcus (GAS), is responsible for various conditions, such as pharyngitis, tonsillitis, necrotizing fasciitis, and streptococcal toxic shock syndrome (STSS). STSS, a rapidly progressing infection involving shock and multi-organ failure, was first reported in Japan in 1992, and since then, the number of cases has been steadily increasing. We herein report an autopsy case of STSS that resulted in sudden death. The patient was a 67-year-old woman who died 100 minutes after walking to the emergency department on her own. This case was characterized by multiple organ failure, septic shock, and a lack of polymorphonuclear leukocyte infiltration in necrotic/infected tissues, which are typical features of STSS. Necrotizing fasciitis of the left lower leg was also identified as a potential cause of STSS in this case. Awareness of this condition is critical, and careful screening and a timely diagnosis are essential to ensure the best possible outcomes for the affected patients. In addition, future vaccination strategies are needed.

Recurrent streptococcal toxic shock syndrome due to distinct episodes of Streptococcus dysgalactiae and Streptococcus agalactiae septic arthritis

Streptococcal toxic shock syndrome (STSS) is an uncommon disorder characterised by hypotension and multiorgan failure in the setting of streptococcal infection. Recurrent STSS is rare and has been due to recurrence of the same streptococcal species. Here, we present a case of a patient who developed recurrent STSS from a Streptococcus dysgalactiae right native joint septic arthritis and subsequently from a Streptococcus agalactiae left native joint septic arthritis.

Streptococcal toxic shock syndrome due to Streptococcus dysgalactiae subsp. equisimilis from retroperitoneal panniculitis during the treatment with anti-IL-6 receptor antibody: A case report

A 53-year-old man with adult-onset Still's disease developed severe streptococcal toxic shock syndrome (STSS) due to Streptococcus dysgalactiae subsp. equisimilis (SDSE), following retroperitoneal panniculitis. He was receiving tocilizumab (TCZ), an interleukin-6 receptor inhibitor. The modifying effect of TCZ on the immune response and the pathophysiology of SDSE infection may have led to retroperitoneal panniculitis and atypical STSS with delayed shock and flare of soft tissue inflammation.

A multimodality review of gynecologic devices in the pelvis

There are a wide variety of gynecologic devices encountered on pelvic imaging which may not be the focus or primary reason for imaging. Such devices include pessaries, menstrual products, radiation therapy devices, tubal occlusion devices, and contraceptive devices, including intrauterine devices and intravaginal rings. This manuscript offers a comprehensive review of multimodality imaging appearances of gynecologic devices encountered on pelvic imaging and discusses device indications, positioning, and complications.

Toxic Shock Syndrome as an Unexpected Complication in Outpatient Pediatric Burn Treatment: A Chart Review

Background: Minor burn injuries in children affecting less than 10% of total body surface area (TBSA) are often successfully managed in the outpatient setting, however it is important to recognize they can be associated with serious sequelae such as toxic shock syndrome (TSS). Methods: We conducted a retrospective chart review at a tertiary-level pediatric hospital between May 2012 and May 2022 to identify pediatric patients diagnosed with TSS following minor burn injuries. Data collected included: patient demographics, burn characteristics, TSS symptoms, and management. Data was analyzed using descriptive statistics. Results: During the study period, 3706 patients with minor burns were treated as outpatients, of which 6 patients developed TSS. Ages ranged from 12 to 36 months, and half were male. Most injuries were scalds (n = 4) or contact injuries (n = 2), involving 1% to 3% TBSA partial-thickness burns. Early symptoms of TSS included vomiting (n = 6) and fever (n = 5), and later, hypotension (n = 5). Hospital admission for TSS occurred 1 to 6 days post-injury. Four of the 6 patients required ICU care, with 2 of them requiring fluid resuscitation and 2 receiving IVIg. The clinical course of 2 patients was complicated by deep vein thrombosis, with 1 patient developing a septic ileus as a secondary infection. All patients recovered and were discharged home after 3 to 9 days. Conclusion: We highlight the rare complication of TSS following minor burns in children. Providers should be vigilant for early symptoms of TSS like fever, vomiting, and hypotension. Further research to identify at-risk patients and preventative treatment would be beneficial.

A Diagnostic Dilemma: Clindamycin-Resistant Group A Streptococcal Toxic Shock Syndrome Leading to Acute Respiratory Distress Syndrome (ARDS) With Multiple Possible Sources

Group A Streptococcal (GAS) infections can potentially progress into streptococcal toxic shock syndrome (STSS) with multiorgan failure. Even with a benign presentation, GAS can rapidly lead to fatal necrotizing infections. While myositis and cutaneous infections are the typical initial presentation of STSS, genitourinary infections are a less common source. This report presents a case of a previously healthy woman with the chief complaint of ankle pain who subsequently developed streptococcal toxic shock syndrome and multiorgan failure from a Group A streptococcus infection of the genitourinary tract. She was treated with antibiotics and medical management for her septic shock and required prone ventilation for her acute respiratory distress syndrome (ARDS) but eventually recovered without surgery. This case highlights the importance of recognizing unusual presentations of Group A Strep infections, which have the potential to lead to rapid deterioration in patients. Also described are antibiotic and ventilator strategies that can be used to treat these severe systemic infections.

Sequential Extracorporeal Therapy of Pathogen Removal Followed by Cell-Directed Extracorporeal Therapy in Streptococcal Toxic Shock Syndrome Refractory to Venoarterial Extracorporeal Membrane Oxygenation: A Case Report

BACKGROUND

Streptococcal toxic shock syndrome (STSS) is a fulminant complication of predominantly invasive group A streptococcal infections. STSS is often characterized by influenza-like symptoms, including fever, chills, and myalgia that can quickly progress to sepsis with hypotension, tachycardia, tachypnea, and multiple organ failure (kidney, liver, lung, or blood). Mortality can exceed 50% depending on the severity of symptoms.

CASE SUMMARY

Here, we describe a novel, multi-extracorporeal intervention strategy in a case of severe septic shock secondary to STSS. A 28-year-old woman 5 days after cesarean section developed STSS with respiratory distress, hypotension, and multiple organ failure. Despite conventional therapy with intubation, antibiotics, vasopressors, and fluid resuscitation, her condition worsened. She was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) with subsequent initiation of pathogen hemoperfusion using the Seraph 100 blood filter, followed by immunomodulation with the selective cytopheretic device (SCD). No device-related adverse events were observed. The patient's condition gradually stabilized with discontinuation of vasopressors after 4 days, ECMO decannulation after 6 days, evidence of renal recovery after 7 days, and extubation from mechanical ventilation after 14 days. She was transferred to conventional hemodialysis after 13 days and discontinued all kidney replacement therapy 11 days later.

CONCLUSIONS

This is the first reported use of VA-ECMO, Seraph 100 hemoperfusion, and cell-directed immunomodulation with SCD. This multimodal approach to extracorporeal support represents a promising therapeutic strategy for the most refractory critical care cases. Further studies are needed to assess the safety and efficacy of this sequential approach.

A Critical Case of Streptococcal Toxic Shock Syndrome: A Case Report

A 41-year-old woman with a history of asthma presented to the emergency department with complaints of progressive malaise, dyspnea, vomiting, and diarrhea for a week. Upon presentation, the patient was hemodynamically unstable and exhibited severe respiratory distress. A chest computed tomography revealed consolidation of the left upper lobe with confluence in the left perihilar region and a left pleural effusion. The patient was admitted to the intensive care unit for further management of respiratory failure, and a chest tube was placed on the left side. Despite the absence of bacteremia, the diagnosis of Streptococcal toxic shock syndrome was confirmed through a pleural fluid culture positive for Streptococcus pyogenes and evidence of multiorgan failure. Her treatment included vasopressors, broad-spectrum antibiotics, and intravenous immunoglobulin. For renal failure, the patient required continuous renal replacement therapy. Despite all these interventions, the patient continued to decline, and left-sided video-assisted thoracoscopic surgery was pursued with subsequent improvement of her condition. The incidence of invasive Group A streptococcal disease is significant, with notable mortality and morbidity among affected patients. The rapid deterioration is thought to be secondary to the highly virulent nature of the pathogen and the production of superantigens. The rapid institution of adequate antibiotic coverage with beta-lactams and clindamycin has been shown to decrease the mortality rate. Intravenous immunoglobulin has also been included with a promising positive effect.

Catastrophic Streptococcus pyogenes Disease: A Personalized Approach Based on Phenotypes and Treatable Traits

Streptococcal toxic shock syndrome (STTS) is a critical medical emergency marked by high morbidity and mortality, necessitating swift awareness, targeted treatment, and early source control due to its rapid symptom manifestation. This report focuses on a cohort of 13 patients admitted to Vall d'Hebron University Hospital Intensive Care Unit, Barcelona, from November 2022 to March 2023, exhibiting invasive Streptococcus pyogenes infections and meeting institutional sepsis code activation criteria. The primary infections were community-acquired pneumonia (61.5%) and skin/soft tissue infection (30.8%). All patients received prompt antibiotic treatment, with clinical source control through thoracic drainage (30.8%) or surgical means (23.1%). Organ support involved invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy as per guidelines. Of note, 76.9% of patients experienced septic cardiomyopathy, and 53.8% required extracorporeal membrane oxygenation (ECMO). The study identified three distinct phenotypic profiles-hyperinflammatory, low perfusion, and hypogammaglobulinemic-which could guide personalized therapeutic approaches. STTS, with a mean SOFA score of 17 (5.7) and a 53.8% requiring ECMO, underscores the need for precision medicine-based rescue therapies and sepsis phenotype identification. Integrating these strategies with prompt antibiotics and efficient source control offers a potential avenue to mitigate organ failure, enhancing patient survival and recovery in the face of this severe clinical condition.

Clinical and molecular epidemiological features of critically ill patients with invasive group A Streptococcus infections: a Belgian multicenter case-series

BACKGROUND

Recent alerts have highlighted an increase in group A streptococcal (GAS) infections since 2022 in Europe and the United States. Streptococcus pyogenes can cause limited skin or mucosal disease, but can also present as severe invasive disease necessitating critical care. We performed a multicenter retrospective study of patients with GAS infections recently admitted to Belgian intensive care units (ICUs) since January 2022. We describe patient characteristics and investigate the molecular epidemiology of the S. pyogenes strains involved.

RESULTS

Between January 2022 and May 2023, a total of 86 cases (56 adults, 30 children) with GAS disease were admitted to critical care in the university hospitals of Leuven, Antwerp and Liège. We noted a strikingly high incidence of severe community-acquired pneumonia (sCAP) (45% of adults, 77% of children) complicated with empyema in 45% and 83% of adult and pediatric cases, respectively. Two-thirds of patients with S. pyogenes pneumonia had viral co-infection, with influenza (13 adults, 5 children) predominating. Other disease presentations included necrotizing fasciitis (23% of adults), other severe skin/soft tissue infections (16% of adults, 13% of children) and ear/nose/throat infections (13% of adults, 13% of children). Cardiogenic shock was frequent (36% of adults, 20% of children). Fifty-six patients (65%) had toxic shock syndrome. Organ support requirements were high and included invasive mechanical ventilation (77% of adults, 50% of children), renal replacement therapy (29% of adults, 3% of children) and extracorporeal membrane oxygenation (20% of adults, 7% of children). Mortality was 21% in adults and 3% in children. Genomic analysis of S. pyogenes strains from 55 out of 86 patients showed a predominance of emm1 strains (73%), with a replacement of the M1global lineage by the toxigenic M1UK lineage (83% of emm1 strains were M1UK).

CONCLUSIONS

The recent rise of severe GAS infections (2022-23) is associated with introduction of the M1UK lineage in Belgium, but other factors may be at play-including intense circulation of respiratory viruses and potentially an immune debt after the COVID pandemic. Importantly, critical care physicians should include S. pyogenes as causative pathogen in the differential diagnosis of sCAP.

Managing the deteriorating child with suspected group A Streptococcus infection

Group A Streptococcus bacteria can cause various pyogenic infections such as tonsillitis, pharyngitis, scarlet fever, impetigo, erysipelas, cellulitis and pneumonia. Most group A Streptococcus infections in children are mild and respond positively to treatment with antibiotics. However, some children develop severe infection accompanied by complications such as sepsis and will require urgent treatment, which may include non-invasive or invasive ventilation and the administration of fluids and vasoactive agents. In some instances, for example if there are no beds available in the paediatric intensive care unit, these interventions may be undertaken in a ward setting. This article gives an overview of group A Streptococcus infection, including two rare but severe complications, streptococcal toxic shock syndrome and necrotising fasciitis. It uses a fictionalised case study to examine the management of the deteriorating child with suspected group A Streptococcus infection, including respiratory support, haemodynamic support and symptom management.

Streptococcal toxic shock syndrome with associated necrotising fasciitis necessitating amputation of the lower extremity - A case report

Streptococcal toxic shock syndrome is a severe, invasive and life-threatening infection associated with a high risk of rapid multiorgan failure. It is associated with high morbidity and mortality. Streptococcal toxic shock syndrome is very commonly caused by group A-Streptococcus pyogenes, ß-haemolytic streptococcus, a typical human-specific gram-positive bacterial pathogen. We present here the case report of a 54-year-old man with a rapidly progressive streptococcal toxic shock syndrome due to necrotising fasciitis of the left lower limb and describe the successful treatment through close interdisciplinary care.

Venoarterial extracorporeal membrane oxygenation for group B streptococcal toxic shock syndrome: A case report and literature review

RATIONALE

Streptococcal toxic shock syndrome (STSS) rapidly leads to refractory shock and multiple organ failure. The mortality rate among patients with STSS is 40%; however, most deaths occur within a few days of onset. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) may help avoid acute death in adult patients with STSS. However, the effectiveness of VA-ECMO is unclear. In this study, we report a case of group B STSS, which was successfully treated with VA-ECMO despite cardiopulmonary arrest (CPA) owing to rapidly progressive refractory shock.

PATIENT CONCERNS

A 60-year-old woman was hospitalized because of diarrhea and electrolyte abnormalities owing to chemoradiation therapy for rectal cancer. A sudden deterioration of her condition led to CPA. Conventional cardiopulmonary resuscitation was immediately performed but was ineffective. Therefore, VA-ECMO was initiated. Contrast-enhanced computed tomography revealed duodenal perforation. Hence, septic shock owing to peritonitis was diagnosed, and emergency surgery was performed under VA-ECMO. However, the patient had progressive multiple organ failure and required organ support therapy in the intensive care unit (ICU).

DIAGNOSES

On day 2 in the ICU, blood and ascites fluid culture tests revealed beta-hemolytic streptococci, and the patient was finally diagnosed as having STSS caused by Streptococcus agalactiae.

INTERVENTIONS

Clindamycin was added to meropenem, vancomycin, and micafungin, which had been administered since the sudden deterioration. In addition, VA-ECMO, mechanical ventilation, blood purification therapy, and treatment for disseminated intravascular coagulation were continued.

OUTCOMES

Thereafter, hemodynamics improved rapidly, and the patient was weaned off VA-ECMO on day 5 of ICU admission. She was transferred to a general ward on day 22 in the ICU.

LESSONS

In patients with fatal STSS and rapid progressive refractory shock or CPA, VA-ECMO may help to avoid acute death and improve prognosis by ameliorating tissue oxygenation and providing extra time to treat invasive streptococcal infection.

Streptococcal Bacteremia and Toxic Shock Syndrome: A Rare Etiology Requiring Prompt Diagnosis

Bullous impetigo leading to streptococcal toxic shock syndrome (STSS) immune activation and massive cytokine release is a rare condition. It has a significant mortality rate, which calls for quick diagnosis, early suspicion, and integrated treatment. Herein, we discuss the case of a 66-year-old man who underwent evaluation for leg swelling before quickly going into shock and experiencing respiratory failure, which necessitated invasive mechanical intubation. Streptococcus pyogenes was identified by blood culture, and STSS was identified. Recommended antibiotics, intravenous (IV) immunoglobulin, and fluids made up the treatment regimen. In this case, the streptococcal infection deteriorated very quickly, and there was a rare relationship with bullous impetigo, which led to shock and respiratory failure. This case sheds lights on the need of having an early suspicion of this syndrome when a diabetic patient develops a skin lesion. A prompt diagnosis is necessary.

Atypical Case Presentation of Toxic Shock Syndrome

Toxic shock syndrome is a rare and life-threatening condition that is typically caused by group A Streptococcus or Staphylococcus aureus. It classically presents with fever, hypotension, sunburn-like rash, and multi-organ system failure. We describe a case of a 70-year-old male with this condition who had an atypical presentation of left chest wall pain and left shoulder pain after two mechanical falls along with hemodynamic stability. The patient rapidly deteriorated on his second hospital floor day, resulting in a higher complexity of care and management in the intensive care unit (ICU). Despite a number of resuscitative measures, therapies, and multidisciplinary care, the patient unfortunately passed away within 24 hours of his ICU care.

Novel evidence on sepsis-inducing pathogens: from laboratory to bedside

Sepsis is a life-threatening condition and a significant cause of preventable morbidity and mortality globally. Among the leading causative agents of sepsis are bacterial pathogens Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pyogenes, along with fungal pathogens of the Candida species. Here, we focus on evidence from human studies but also include in vitro and in vivo cellular and molecular evidence, exploring how bacterial and fungal pathogens are associated with bloodstream infection and sepsis. This review presents a narrative update on pathogen epidemiology, virulence factors, host factors of susceptibility, mechanisms of immunomodulation, current therapies, antibiotic resistance, and opportunities for diagnosis, prognosis, and therapeutics, through the perspective of bloodstream infection and sepsis. A list of curated novel host and pathogen factors, diagnostic and prognostic markers, and potential therapeutical targets to tackle sepsis from the research laboratory is presented. Further, we discuss the complex nature of sepsis depending on the sepsis-inducing pathogen and host susceptibility, the more common strains associated with severe pathology and how these aspects may impact in the management of the clinical presentation of sepsis.

Antiphospholipid syndrome after streptococcal toxic shock syndrome later diagnosed as Behcet's disease

Streptococcal toxic shock syndrome is a severe complication of group A streptococci. The production of antiphospholipid antibodies has been associated with streptococcal infections and with autoimmune diseases. Furthermore, streptococcal infections could be a trigger of Behcet's disease. We report a case of a boy who presented antiphospholipid syndrome after streptococcal toxic shock syndrome later he was diagnosed with Behcet's disease.

Necrotizing fasciitis and septic shock due to streptococcal toxic shock syndrome in an elderly patient: A case report

Streptococcal toxic shock syndrome (STSS) has a high mortality rate, and most patients die within a few days of onset. We report an elderly patient with STSS, necrotizing fasciitis and septic shock caused by group G streptococcus who was successfully treated with multidisciplinary therapy.

Not so uncommon, yet neglected 'Severe Streptococcus pyogenes infections at a tertiary care center in south India

Streptococcus pyogenes (SP) causes uncomplicated infections of throat & skin to severe life-threatening invasive diseases and poststreptococcal sequelae. Despite being common, it hasn't been studied much in recent times. Data of 93 adult patients >18 years, culture proven (SP) infections from 2016 to 2019 was studied in south India. Irrespective of comorbidities, SSTI were most common followed by surgical site infections& bacteremia. Isolates were susceptible to penicillin, cephalosporins but 23% were resistant to clindamycin. Timely surgical interventions and appropriate antibiotics reduced morbidity& limb salvage by 9 times. Larger studies, worldwide, to see the current trend of SP need to be conducted.

TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses

Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.

Streptococcal Toxic Shock Syndrome: A Case Report

Streptococcal toxic shock syndrome is a serious complication of group A Streptococcus infection with a high mortality rate. Rapid detection, early intensive care support, and surgical management are paramount in treating these patients. We present a case of a 65-year-old male, with a documented medical history of hypertension, type 2 diabetes mellitus, and peripheral arterial disease. The patient was evaluated in the emergency department with a chief complaint of pain, swelling in his left leg, and fever. Physical examination showed tachycardia, hypotension, and clear inflammatory signs in the left leg. After initial clinical and laboratory evaluation, the patient was admitted with a diagnosis of cellulitis and urinary tract infection. He presented progressive worsening with multi-organ dysfunction, requiring vasopressor support, invasive mechanical ventilation, and renal replacement therapy. Streptococcus pyogenes was isolated in blood cultures, and a streptococcal toxic shock syndrome was considered. Appropriate antibiotic therapy, immunoglobulins, hemoperfusion, and corticosteroid therapy were administered, with clinical improvement. During hospitalization, there was a progressive improvement in the skin lesion. Once clinically stabilized the patient was discharged with follow-up. The case presented shows the rapid evolution of cutaneous streptococcal infection with multiorgan dysfunction. Although these types of infections have an associated high mortality rate, this patient survived. The use of immunoglobulin and hemoperfusion technique, in this case, might have contributed to this positive outcome. Therefore, we highlight the need for high suspicion of this syndrome, especially in diabetic patients presenting with skin lesions. Once the diagnosis is established, these infections require close surveillance and rapid and intensive treatment.

Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis

OBJECTIVES

To quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies.

ELIGIBILITY CRITERIA

Pairs of reviewers independently screened potentially eligible studies of patients with Group A Streptococcus-induced STSS that quantified the association between at least one prognostic factor and outcome of interest.

DATA EXTRACTION AND SYNTHESIS

We performed random-effects meta-analysis after duplicate data extraction and risk of bias assessments. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

One randomised trial and 40 observational studies were eligible (n=1918 patients). We found a statistically significant association between clindamycin treatment and mortality (n=144; OR 0.14, 95% CI 0.06 to 0.37), but the certainty of evidence was low. Within clindamycin-treated STSS patients, we found a statistically significant association between intravenous Ig treatment and mortality (n=188; OR 0.34, 95% CI 0.15 to 0.75), but the certainty of evidence was also low. The odds of mortality may increase in patients ≥65 years when compared with patients 18-64 years (n=396; OR 2.37, 95% CI 1.47 to 3.84), but the certainty of evidence was low. We are uncertain whether non-steroidal anti-inflammatory drugs increase the odds of mortality (n=50; OR 4.14, 95% CI 1.13 to 15.14; very low certainty). Results failed to show a significant association between any other prognostic factor and outcome combination (very low to low certainty evidence) and no studies quantified the association between a prognostic factor and morbidity post-infection in STSS survivors.

CONCLUSIONS

Treatment with clindamycin and within clindamycin-treated patients, IVIG, was each significantly associated with mortality, but the certainty of evidence was low. Future research should focus on morbidity post-infection in STSS survivors.

PROSPERO REGISTRATION NUMBER

CRD42020166961.

Engineered Liposomes Protect Immortalized Immune Cells from Cytolysins Secreted by Group A and Group G Streptococci

The increasing antibiotic resistance of bacterial pathogens fosters the development of alternative, non-antibiotic treatments. Antivirulence therapy, which is neither bacteriostatic nor bactericidal, acts by depriving bacterial pathogens of their virulence factors. To establish a successful infection, many bacterial pathogens secrete exotoxins/cytolysins that perforate the host cell plasma membrane. Recently developed liposomal nanotraps, mimicking the outer layer of the targeted cell membranes, serve as decoys for exotoxins, thus diverting them from attacking host cells. In this study, we develop a liposomal nanotrap formulation that is capable of protecting immortalized immune cells from the whole palette of cytolysins secreted by Streptococcus pyogenes and Streptococcus dysgalactiae subsp. equisimilis—important human pathogens that can cause life-threatening bacteremia. We show that the mixture of cholesterol-containing liposomes with liposomes composed exclusively of phospholipids is protective against the combined action of all streptococcal exotoxins. Our findings pave the way for further development of liposomal antivirulence therapy in order to provide more efficient treatment of bacterial infections, including those caused by antibiotic resistant pathogens.

Post-surgical staphylococcal toxic shock syndrome in pediatrics: A case report

Introduction

Toxic shock syndrome (TSS) is a rare but serious, life-threatening medical condition and potentially lethal if not detected and treated early. It is mainly caused by a toxin called toxin-1 produced by Staphylococcus aureus, and characterized by fever, hypotension, rash, skin desquamation and multisystem involvement.

Case presentation

Herein, we describe a nine-month-old male patient who presented to the hospital complaining of fever, vomiting and hypoactivity on day one post-orchidopexy. During hospitalization, his condition began to deteriorate with signs and symptoms of multisystemic failure. Laboratory tests and radiological images were done, leading to the decision to reopen and drain the surgical wound. Wound and nasal swabs were cultured and showed S. aureus infection, and the diagnosis of toxic shock syndrome was confirmed.

Discussion

TSS is a systemic illness resulting from overwhelming host response to bacterial exotoxins, that cause T cells activation and the release of pro-inflammatory cytokines (IL-1 and TNF-α causing fever, hypotension, and tissue injury). Also, it can present with CNS signs that may be misdiagnosed with meningitis in pediatrics.

It requires early identification and treatment despite its rarity with mortality rate of 81% even with treatment.

The patient's presentation, examination and laboratories tests with the blood and wound cultures were highly suggestive for this condition.

Conclusion

Physicians must maintain a high index of suspicion for TSS, as early diagnosis and treatment make a difference. This condition shouldn't be excluded even in young age patients or after simple procedure as in our case in which TSS occurred after orchidopexy.

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Toxic shock syndrome is a life-threatening condition that can be highly mortal even with treatment.

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Post-surgical TSS is very rare and according to the literature this is the first reported case post-orchidopexy.

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Broad spectrum antibiotics with debridement of the necrotic tissue as management are the best option to treat this condition.

AR-12 Has a Bactericidal Activity and a Synergistic Effect with Gentamicin against Group A Streptococcus

Streptococcus pyogenes (group A Streptococcus (GAS) is an important human pathogen that can cause severe invasive infection, such as necrotizing fasciitis and streptococcal toxic shock syndrome. The mortality rate of streptococcal toxic shock syndrome ranges from 20% to 50% in spite of antibiotics administration. AR-12, a pyrazole derivative, has been reported to inhibit the infection of viruses, intracellular bacteria, and fungi. In this report, we evaluated the bactericidal activities and mechanisms of AR-12 on GAS infection. Our in vitro results showed that AR-12 dose-dependently reduced the GAS growth, and 2.5 μg/mL of AR-12 significantly killed GAS within 2 h. AR-12 caused a remarkable reduction in nucleic acid and protein content of GAS. The expression of heat shock protein DnaK and streptococcal exotoxins was also inhibited by AR-12. Surveys of the GAS architecture by scanning electron microscopy revealed that AR-12-treated GAS displayed incomplete septa and micro-spherical structures protruding out of cell walls. Moreover, the combination of AR-12 and gentamicin had a synergistic antibacterial activity against GAS replication for both in vitro and in vivo infection. Taken together, these novel findings obtained in this study may provide a new therapeutic strategy for invasive GAS infection.

Fulminant necrotizing streptococcal myositis with dramatic outcome - a rare case report

Necrotizing myositis represents a rare, aggressive form of bacterial-induced soft tissue necrotizing infection. We present a fulminant case of a 44-year-old patient with a necrotizing soft tissue infection and a history of rheumatoid arthritis transferred to our service, Cluj-Napoca Emergency County Hospital, from a local hospital where he had been admitted two days before with chills and light-headedness after an accidental minor blunt trauma in the right thigh region. After admission to our hospital and first assessment, broad spectrum antibiotherapy was started with Meropenem, Vancomycin and Metronidazole along with surgical debridement. The evolution was fulminant with rapid development of multiple organ dysfunction syndrome, therefore he was transferred to the intensive care unit, intubated, and started the volemic resuscitation and vasopressor therapy. The blood culture was positive for group A beta-hemolytic streptococcus (GAS) and high dose Penicillin G was added to the therapeutic scheme. Despite all efforts, the patient developed disseminated intravascular coagulation syndrome and died in the next hours. The clinical picture together with the findings from the autopsy were suggestive for a streptococcal toxic shock syndrome developed as a complication of GAS induced necrotizing myositis.

Next-generation sequencing of 16S rRNA for identification of invasive bacterial pathogens in a formalin-fixed paraffin-embedded placental specimen: a case report of perinatal fulminant Streptococcus pyogenes infection

Intrauterine infection is one of the most important causes of maternal death. In perinatal emergency, we often miss an opportunity to obtain culture specimens. In this study, we tried to examine whether we investigated whether bacteria causing infection can be detected from a formalin-fixed paraffin-embedded (FFPE) placental specimen. We examined the placenta from a maternal invasive infection that resulted in infectious abortion at 18 weeks of gestation. The case was diagnosed by acute fever and abdominal pain, and the patient was cured after 3 weeks of intensive antimicrobial treatment. Four Streptococcus pyogenes strains were isolated from vaginal fluid and blood cultures of the patient. All of the strain types were emm1/ST28. We amplified the V1-V2 region of 16S rRNA from an FFPE placental specimen and sequencing was performed using a next-generation sequencer (NGS). Taxonomic analysis was then performed for sequenced data. We succeeded in detecting causative pathogens from the FFPE placenta: 69.1% of the predominantly identified bacteria were S. pyogenes and other small populations of bacteria were detected. Our results revealed the utility of NGS for 16S rRNA analysis of an FFPE placenta. This method may reveal previous perinatal invasive infections of unknown origin retrospectively.

Sepsis-Pathophysiology and Therapeutic Concepts

Sepsis is a life-threatening condition and a global disease burden. Today, the heterogeneous syndrome is defined as severe organ dysfunction caused by a dysregulated host response to infection, with renewed emphasis on immune pathophysiology. Despite all efforts of experimental and clinical research during the last three decades, the ability to positively influence course and outcome of the syndrome remains limited. Evidence-based therapy still consists of basic causal and supportive measures, while adjuvant interventions such as blood purification or targeted immunotherapy largely remain without proof of effectiveness so far. With this review, we aim to provide an overview of sepsis immune pathophysiology, to update the choice of therapeutic approaches targeting different immunological mechanisms in the course of sepsis and septic shock, and to call for a paradigm shift from the pathogen to the host response as a potentially more promising angle.

When All Else Fails: A Rare Case of Postoperative Toxic Shock Syndrome Arising from Surgical Site Infection after Decompressive Neurectomy Successfully Treated with Angiotensin-2

Toxic shock syndrome is a serious complication of Streptococcus pyogenes or Staphylococcus aureus infections associated with very high morbidity and mortality. Postoperative toxic shock syndrome is an extremely rare phenomenon which manifests as fevers, diffuse rash, septic shock, and death. We present the first reported case of toxic shock syndrome associated with a surgical site infection from a decompressive neurectomy for refractory migraines in a 41-year-old female as well as the first use of angiotensin-2 vasopressor therapy to treat persistent septic shock from toxic shock syndrome refractory to conventional therapies.

Streptococcal toxic shock syndrome with fatal outcome: Report on four forensic autopsy cases

Streptococcal toxic shock syndrome (STSS) is a severe infection most commonly caused by group A streptococcus. It is clinically characterized by rapidly progressive multiple organ failure and septic shock. This report presents four fatal cases associated with STSS. In two cases (cases 2 and 3), the portals of entry may be ulcer and mucosa at the surgical site; the initial symptoms in these cases included fever. In the other cases, the portal of entry was unknown; the initial symptom was pain. In two cases (cases 1 and 3), malpractice was suspected before autopsy. At autopsy, blood culture was positive for group A streptococcus in all of the present cases. Although C-reactive protein levels were increased, procalcitonin levels were not markedly elevated. This is the first report of autopsy cases associated with STSS in which postmortem computed tomography was performed; the swelling of muscles and increased concentrations of peripheral subcutaneous tissue without gas may be characteristic findings. Histology revealed extensive bacterial colonies and necrosis with mild neutrophilic reaction in two cases (cases 3 and 4), and hemophagocytosis in two cases (cases 1 and 4). It is essential to perform appropriate examinations and make a proper diagnosis because STSS still has a high fatality rate and medical malpractice is often suspected. In addition, it is important to evaluate STSS again for the reduction of the fatal cases associated with STSS.

A case report of streptococcal toxic shock syndrome caused by Streptococcus mitis in a healthy adult

BACKGROUND

Streptococcal toxic shock syndrome (STSS) is an acute, multisystem and toxin-mediated disease that usually causes shock and multiple organ failure in the early stages of its clinical course. It is associated with a substantial increase in mortality rate. The disease has been associated with invasive group A Streptococcus and is rarely caused by Streptococcus mitis (S. mitis). In healthy adults, S. mitis is closely related to endocarditis but rarely related to STSS.

CASE PRESENTATION

We report a case of STSS caused by S. mitis in a healthy 45-year-old woman. She presented with fever 14 h after surgery and with hypotension 24 h later, and she subsequently suffered from septic shock, low albumin, dysfunction of coagulation, acute kidney dysfunction, respiratory alkalosis and metabolic acidosis, acute respiratory distress syndrome and cellulitis of the incision. The diagnosis was obtained through clinical manifestation and blood culture examination. The patient was treated with aggressive fluid resuscitation, adequate antibiotics for a total of 4 weeks, respiratory support, and surgical debridement and drainage of the incision. She was discharged after her vital signs returned to normal and the incision healed on day 40 after surgery.

CONCLUSIONS

The diagnosis of STSS is often delayed or missed, which leads to a high mortality rate. It is possible to cure patients if the disease can be identified early and treated with aggressive fluid resuscitation, adequate antibiotics and control of the source of infection. Clinicians should consider the disease in the differential diagnosis of septic shock to prevent death.

Clinical Efficacy of Intravenous Immunoglobulins in Management of Toxic Shock Syndrome: An Updated Literature Review

Toxic shock syndrome (TSS) is an uncommon complication of infection caused by streptococci and staphylococci. It is associated with a high mortality rate. When evaluating patients with shock symptoms from skin or soft tissue sources, a high index of suspicion for TSS must be maintained. Prompt diagnosis and integrative management with surgical intervention, antibiotics, hemodynamic stabilization, and adjuvants like intravenous immunoglobulins improve survival.

Carvacrol exhibits rapid bactericidal activity against Streptococcus pyogenes through cell membrane damage

Streptococcus pyogenes is an important human pathogen worldwide. The identification of natural antibacterial phytochemicals has renewed interest due to the current scarcity of antibiotic development. Carvacrol is a monoterpenoid found in herbs. We evaluated carvacrol alone and combined with selected antibiotics against four strains of S. pyogenes in vitro. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of carvacrol against S. pyogenes were 125 µg/mL (0.53 mM) and 250 µg/mL (1.05 mM), respectively. Kill curve results showed that carvacrol exhibits instantaneous bactericidal activity against S. pyogenes. We also demonstrated the potential mechanism of action of carvacrol through compromising the cell membrane integrity. Carvacrol induced membrane integrity changes leading to leakage of cytoplasmic content such as lactate dehydrogenase enzymes and nucleic acids. We further confirmed dose-dependent rupturing of cells and cell deaths using transmission electron microscopy. The chequerboard assay results showed that carvacrol possesses an additive-synergistic effect with clindamycin or penicillin. Carvacrol alone, combined with clindamycin or penicillin, can be used as a safe and efficacious natural health product for managing streptococcal pharyngitis.

Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives

Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.