Streptococcal Toxic Shock Syndrome. Ellen Collett, M.D. AIM Presentation March 27, 2002. Case:.
Ellen Collett, M.D.
March 27, 2002
M.B. is a 73 yo white female admitted from an outside hospital to the Plastic Surgery Service for I+D of her right thumb. The patient reported a cut to her hand about 2 days prior to presenting to the outside hospital. She was working in the yard, but she does not remember specifically how she cut her thumb. At home she began experiencing nausea, vomiting, diarrhea, chills, ? fevers, and pain in her thumb. At the outside hospital she underwent I+D of her thumb and was placed on Levaquin. Her thumb worsened and three days later she was transferred to NCBH. On admission she underwent I+D of right thumb and she was started on Unasyn. The following evening the patient become hypoxic with sats 88-93% on 2 L NC. She became progressively worse with sats at 90% on 3L. Internal Medicine was consulted the following day. The patient had sats of 89% on 3 L. She did not complain of SOB or chest pain. She reported a slight occasional cough. She had not experienced N/V/D since her admission at the outside hospital. Overall she feels improved since her admission.
MEDS: Norvasc 5 mg qd, Atenolol 25 mg qd, Celebrex 200 mg qd,
Premarin 0.625 mg qd, Lasix 20 mg qd, Synthroid .75 mg qd, Zoloft 100 mg qd,
Depakene 350 mg bid, Unasyn 3000 mg q 6h, Heparin 5000 u SC bid
FH: son with DM
SH: no tobacco use and no history of tobacco use, no alcohol or drug use.
Homemaker in Bluefield, WV.
PE: T 97.8 Tmax 100, BP 102/54, 89% 3 L NC, pulse 70’s, RR 20
elderly female in NAD
PERRL, EOMI, OP clear
neck supple, no LAD
S1, S2 regular, no M/R/G
lungs with crackles bilaterally
abd soft, NT, ND, BS +
extremities without edema, right thumb with dressing
skin without rashes
Echo: EF 55%, no segmental wall abnormalities
CXR 3/13 Bilateral airspace disease
CXR 3/15 interval improvement but findings c/w pulm edema. Superimposed infection can not be ruled out
Labs:on admission: wbc 13.6, hgb 12.3, plt 216, 74% segs, 2% bands,
13% lymphs, Na 140, K 3.5, Cl 103, CO2 26, BUN 13, Cr 1.1 Gluc 108,
Ca 8.6. PT 10.7, PTT 28.4, INR 0.78
Wound culture: 4+ beta hemolytic GAS
day of consult wbc 10.2 hgb 11.9, plt 308. Na 135, K 3.4, Cl 95, CO2 26, BUN 16 Cr 1.2, Gluc 115, Ca 7.7, Prot 6, Alb 3, Tbili 0.9, Alk Phos 142, AST 36, ALT 37, CK 37, Tn <0.1 ABG 7.4/43.5/64/28/93% on 3L
Azithromycin and Doxycycline. She remained afebrile and her blood pressures
remained stable. She continued to deny SOB or chest pain. Her CXR showed
no improvement. Six days after the I+D, she underwent amputation of the distal
Her chest CT done the same day showed bilateral upper lobe ground glass
attenuation with areas of consolidation c/w pneumonia with some similar
appearing but less extensive areas within right middle lobe and
bilateral lower lobes, small bilateral pleural effusions
The following day she required 80% FS with sats in the low 90’s.
labs wbc 12.2, hgb 10.1, plt 634 65% segs, 1% bands, 27% lymphs
Na 131, K 4.1, Cl 93, CO2 27, BUN 17, Cr 1.2, Gluc 94, Ca 7.7
ABG 7.47/36/56/26/91% on 6 L
She was transferred to Gen Med and placed on Vanc, Gent, and Penicillin.
The following day she improved, requiring 6L NC. Her supplemental
oxygen needs decreased and one week later she was on RA. Blood and urine
cultures were negative.
• Portals of entry for strep are the pharynx, skin and vagina in 50% of cases.
Surgical procedures also provide portals of entry. Rarely infection occurs secondary to streptococcal pharyngitis
• Lack of antibody to superantigens and lack of SPE neutralizing antibodies are associated with development of strep TSS
• 60-100% of patients with streptococcal TSS are bacteremic (unlike staph TSS)
• Mortality rate is higher than with staph TSS--30-50% with fasciitis and up to 80% with myositis
• Development of streptococcal TSS during invasive streptococcal infection correlates with significantly higher mortality
•Lab finding s include elevated creatinine, hemoglobinuria, hypoalbuminemia, hypocalcemia, elevated CK with deeper soft tissue infections, mild leukocytosis with left shift, thrombocytopenia and anemia
Severe Group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin AStevens D, Tanner M, et alNew England Journal of Medicine, 1989
were also seen
• M serotype 1 and 3 most common and 80% of the isolates produced
pyrogenic exotoxin A
• The prevalence of shock, renal failure and mortality was
not significantly different in patients with or without bacteremia
Invasive Group A streptococcal infections in North Carolina: Epidemiology, clinical features and genetic and serotype analysis of causative organismsKiska D, Thiede B, et al. Journal of Infectious Diseases, 1997