Virginia Research Day 2021

Medical Resident Research Case Reports

10 A Case of Severe Streptococcal Toxic Shock Syndrome

Sadia Iqbal, DO, PGY 3; Neeraj Gupta, MD Corresponding author: siqbal@vcom.edu

LewisGale Hospital-Montgomery Salem VA Medical Center

Streptococcal toxic shock syndrome (STSS) is a disease defined as an infection with Streptococcus pyogenes accompanied by sudden onset of shock, organ failure, and frequently death. The two most severe clinical manifestations of GAS are streptococcal toxic shock syndrome (STSS) and necrotizing fasciitis. We present the case of a 54- year-old male admitted with acute onset fever (103.1°F), chills, diaphoresis and dizziness. Patient was hemodynamically unstable. Aggressive fluid resuscitation, vasoactive agents and broad- spectrum antibiotics were initiated. Patient had resection of melanoma of left foot 6 weeks ago followed by integra skin graft placement 3 weeks ago. Streptococcus Pyogenes (Group A Streptococci; GAS) was isolated from initial blood culture on day 1. Broad-spectrum antibiotics were switched to

Penicillin G and Clindamycin. Surgery and Podiatry were consulted for further evaluation. Wound was not considered infected. He continued to deteriorate with multisystem failure despite maximal intensive care therapy. Primary source was not clear yet. On day 2, CT scan of left lower extremity was done that showed small fluid collection in popliteal fossa where lymph node biopsy was performed for staging of melanoma. Patient underwent incision and drainage of posterior left leg abscess with isolation of Streptococcus Pyogenes. Given patient’s worsening status and increased mortality associated with GAS, intravenous immunoglobulin (IVIG) was also initiated per Infectious Disease recommendations. Over the next 24 hours the patient improved, was extubated 1 day later. Patient was subsequently discharged from hospital after 22 days. The objective of this case

study is to review the current knowledge of STSS as well as specific treatment including the use of IVIG. In spite of medical progresses in the care of patients with septic shock, this condition has remained associated with a high mortality. Early recognition and multidisciplinary management are key to the care of patients with STSS. Use of IVIG has remained a controversial subject. Although the evidence for the use of IVIG in severe invasive GAS disease is limited, we feel that on reviewing the available literature use of IVIG in this case was justified and Infectious Disease also recommended it. This case will further add to the limited pool of invasive GAS infections where use of IVIG resulted in improved outcomes including mortality benefits.

46