Streptococcal toxic shock syndrome following group A streptococcal vulvovaginitis in a breastfeeding woman

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.

Genital Tract GAS Infection ISIDOG Guidelines

There has been an increasing worldwide incidence of invasive group A streptococcal (GAS) disease in pregnancy and in the puerperal period over the past 30 years. Postpartum Group A streptococci infection, and in particular streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis, can be life threatening and difficult to treat. Despite antibiotics and supportive therapy, and in some cases advanced extensive surgery, mortality associated with invasive group A streptococcal postpartum endometritis, necrotizing fasciitis, and toxic shock syndrome remains high, up to 40% of postpartum septic deaths. It now accounts for more than 75,000 deaths worldwide every year. Postpartum women have a 20-fold increased incidence of GAS disease compared to non-pregnant women. Despite the high incidence, many invasive GAS infections are not diagnosed in a timely manner, resulting in potentially preventable maternal and neonatal deaths. In this paper the specific characteristics of GAS infection in the field of Ob/Gyn are brought to our attention, resulting in guidelines to improve our awareness, early recognition and timely treatment of the disease. New European prevalence data of vaginal GAS colonization are presented, alongside two original case histories. Additionally, aerobic vaginitis is proposed as a supplementary risk factor for invasive GAS diseases.

A Review of Streptococcus pyogenes: Public Health Risk Factors, Prevention and Control

Streptococcus pyogenes, (colloquially named "group A streptococcus" (GAS)), is a pathogen of public health significance, infecting 18.1 million people worldwide and resulting in 500,000 deaths each year. This review identified published articles on the risk factors and public health prevention and control strategies for mitigating GAS diseases. The pathogen causing GAS diseases is commonly transmitted via respiratory droplets, touching skin sores caused by GAS or through contact with contaminated material or equipment. Foodborne transmission is also possible, although there is need for further research to quantify this route of infection. It was found that GAS diseases are highly prevalent in developing countries, and among indigenous populations and low socioeconomic areas in developed countries. Children, the immunocompromised and the elderly are at the greatest risk of S. pyogenes infections and the associated sequelae, with transmission rates being higher in schools, kindergartens, hospitals and residential care homes. This was attributed to overcrowding and the higher level of social contact in these settings. Prevention and control measures should target the improvement of living conditions, and personal and hand hygiene. Adherence to infection prevention and control practices should be emphasized in high-risk settings. Resource distribution by governments, especially in developed countries, should also be considered.

Early surgery for limb preservation in Group A Streptococcus-induced necrotizing soft tissue infection and subsequent soft tissue infection: A case report

•

This is a case of necrotizing soft tissue infection (NSTI) due to S. pyogenes.

•

Exploration and subsequent debridement led to the limb preservation.

•

Early surgery is crucial for effective treatment of NSTI.

•

Non-necrotizing STI due to S. pyogenes could be possible to reccure at the same limb 2 months later.

•

The patient received antimicrobial treatment without surgery and recovered.

Background

Group A Streptococcus pyogenes (GAS) causes necrotizing soft tissue infections (NSTIs) necessitating exploration, surgical debridement, and possibly limb amputation.

Case presentation

A 45-year-old man presented with traumatic injury of the left carpal region, vomiting, and diarrhea. The swelling and pain in the left forearm worsened with sensorimotor deficits, and his skin color deteriorated. Emergent exploration was performed for limb preservation; GAS was detected in an exudate, and debridement was performed on postoperative day 2 for streptococcal toxic shock syndrome. He recovered uneventfully and was discharged; however, he returned after 2 months with GAS-induced STI at the same site and received antimicrobial treatment.

Conclusion

Exploration and subsequent debridement are crucial for effective treatment of NSTI.

Invasive Group A streptococcal postpartum endometritis associated with multi-organ infarctions: an uncommon case presentation and literature review

Background: Streptococcal Toxic Shock Syndrome (STSS) is a serious condition that can arise from streptococcal postpartum endometritis. It is associated with a substantial increase in mortality rate and can rarely result in multiorgan infarction. Early recognition plays a vital role in patients' outcome. Objective: To report a case of complicated STSS and review the literature for previous case reports of streptococcal postpartum endometritis to determine if STSS diagnostic criteria (published by the Centers for Disease Control and Prevention) were fulfilled. Case presentation: This is a 41-year-old woman who presented 5 days after an uncomplicated vaginal delivery with endometritis complicated by invasive group A β-hemolytic streptococcus (GAS) infection and confirmed toxic shock syndrome. The patient was initially admitted to the critical care unit due to hemodynamic compromise requiring intravenous (IV) fluids, IV antibiotic therapy with penicillin and clindamycin, and IV immunoglobulin therapy. The patient subsequently developed multi-organ infarctions, acute respiratory distress syndrome requiring noninvasive respiratory support, and severe reactive arthritis. Literature review revealed 15 case reports of GAS postpartum endometritis, five met criteria for confirmed STSS. One patient died from severe septic shock leading to cardiopulmonary arrest. Thirteen out of 15 cases of postpartum endometritis occurred after uncomplicated vaginal delivery. Conclusion: STSS is a serious and possibly fatal medical condition that requires early diagnosis and treatment to prevent poor patient outcomes and death. Careful consideration to the patient's postpartum clinical presentation with the implementation of an intradisciplinary approach should be utilized.

Non-Necrotizing Soft Tissue Infection and Streptococcal Toxic Shock Syndrome Caused by a Novel Streptococcus pyogenes Subtype (emm76.10)

We report a case of non-necrotizing soft tissue infection and streptococcal toxic shock syndrome (STSS) caused by a novel emm subtype (emm76.10) of group A Streptococcus pyogenes (GAS). A 54-year-old Japanese woman suffering from fever, fatigue, and lower abdominal pain along with erythema for 3 days was admitted to our hospital. Additionally, she presented with hypotension and multiple organ failure. Exploratory incision was performed due to the presence of STSS and for an examination of the necrotizing soft tissue infection from her lower abdomen to the left thigh. Tissue cultures from the exudates and fascia yielded positive results for GAS growth, although blood cultures returned as negative. After 15 days of antimicrobial therapy, she recovered fully without any complications. Genotyping of the isolate indicated a novel emm subtype (emm76.10), with 5 amino acid substitutions in the emm76.0 subtype sequence and the full-length sequence of 780 bp. This isolate was resistant to tetracyclines, macrolides-lincosamides, and fluoroquinolones, owing to the presence of antibiotic resistance determinants, tet(M) and erm(B), and point mutations, Ser79Phe/Ser81Phe, in the quinolone resistance-determining regions of parC/gyrA. In conclusion, our observations suggest the importance of early-stage exploratory incision and drainage from the infected region for the isolation and characterization of causative bacteria to facilitate selection of appropriate antibiotics for treatment.