Two cases of delayed diagnosis of postpartal streptococcal toxic shock syndrome

How could we suspect life-threatening perinatal group A streptococcal infection?

AIM

Perinatal group A streptococcal infection is a rare but life-threatening condition. Few reports have focused on its clinical characteristics and how to prevent deterioration. We report our experience with two antenatal fatal cases and reviewed 96 cases in the literature to assess the clinical characteristics of group A streptococcal infection.

METHODS

English-language clinical reports of antenatal and postnatal group A streptococcal infection in 1974-2019 were retrieved and examined. Relationships between clinical characteristics and maternal outcomes were assessed.

RESULTS

Univariate analysis revealed that antenatal group A streptococcal infection was significantly associated with an age of ≤19 or ≥ 35 years, cesarean section, sore throat as an initial symptom, positive throat culture, maternal death and fetal death. Multivariate analysis revealed that antenatal onset (odds ratio = 7.922, 95% confidence interval = 1.297-48.374; P = 0.025) and a quick sepsis-related organ-failure assessment score (qSOFA; low blood pressure, high respiratory rate or altered mental status) of ≥2 (odds ratio = 6.166, 95% confidence interval = 1.066-35.670; P = 0.042) were significantly related to maternal death.

CONCLUSION

Per our findings, antenatal group A streptococcal infection was significantly associated with maternal and fetal death. Further, the antenatal infection was revealed as a more critical risk factor. We suggest that the presence of any sign related to the qSOFA is a potential clue suspecting perinatal group A streptococcal infection in primary obstetric facilities.

Ovarian necrosis due to S. pyogenes septic thrombophlebitis: A case report

The incidence of systemic infection attributed to group A streptococci (GAS) is increasing, mainly in postpartum women. Such infections require multidisciplinary management and prompt treatment, but an atypical presentation can delay diagnosis. We report the case of a 24-year-old woman admitted to the emergency department for evaluation. She had acute abdominal pain and fever 18 h after insertion of a levonorgestrel intrauterine device (IUD). She had a normal vaginal delivery 45 days earlier, and no other significant medical background. In a few hours the symptoms worsened, with rapid progression towards multiorgan failure. Differential diagnoses of late ovarian thrombophlebitis and ovarian torsion were considered. Laparoscopic surgery revealed the absence of ovarian torsion. The microbiologic culture of the IUD showed colonization by GAS. The sudden onset of shock-like symptoms in a postpartum woman with rapid progression towards multiorgan failure should prompt consideration of a diagnosis of GAS infection, so that appropriate treatment can be initiated to avoid the possible fatal consequences of this aggressive infection.

Group A Streptococcus Septic Shock after Surgical Abortion: A Case Report and Review of the Literature

Group A Streptococcus (GAS) causing puerperal sepsis is a leading cause of maternal mortality worldwide. Although rare, GAS infection is a relatively significant public health concern because of its propensity to evolve rapidly into septic shock, streptococcal toxic shock syndrome, and death. We report the case of a 27-year-old patient who presented with GAS septic shock after undergoing a surgical termination of pregnancy and was treated successfully and recovered without sequelae. GAS septic shock should always be included in the differential diagnosis of any patient who develops sepsis after a surgical abortion. Patients with GAS septic shock have a rapid clinical decline and need aggressive fluid management, early initiation of broad-spectrum antibiotics, and rapid surgical intervention.

Group A Streptococcal Infection in Pregnancy and the Puerperium

There has been an increasing incidence worldwide of invasive group A streptococcal disease in pregnancy and the puerperal period over the past 30 years. Group A Streptococcus (GAS) was identified as the major cause of maternal morbidity and mortality from sepsis before the identification that hand washing techniques could prevent the transmission of the bacteria. Hand washing remains the cornerstone of prevention as transmission can occur directly from an asymptomatic colonized healthcare provider, other patients, or a community-acquired source. Pregnancy and the puerperal period are associated with significant maternal physiologic changes that must be identified and clarified to identify signs and symptoms of GAS so that treatment can be initiated at the earliest moment. Treatment of group A streptococcal sepsis follows the guidelines developed under the Surviving Sepsis Campaign model. Maternal outcomes are improved by identifying risk factors and working with the perinatal team to implement rapid intervention. Even with prompt treatment of invasive group A Streptococcus, it remains the most common cause of infection that results in severe maternal morbidity and death in the world.

Puerperal group A streptococcal infection: beyond Semmelweis

Ignaz Semmelweiss made one of the most important contributions to modern medicine when he instituted handwashing in an obstetric clinic in Austria in 1847, decreasing mortality there from more than 10% to 2%. Unfortunately, puerperal sepsis remains a leading cause of maternal mortality throughout the world. Group A streptococcus (GAS), Streptococcus pyogenes, is an organism associated with high rates of morbidity and mortality from puerperal infections. When associated with sepsis, known as streptococcal toxic shock syndrome, mortality rates approach 30-50%. Group A streptococcus can cause invasive infections in the form of endometritis, necrotizing fasciitis, or streptococcal toxic shock syndrome. The clinical presentation of women with puerperal GAS infections is often atypical with extremes of temperature, unusual and vague pain, and pain in extremities. Toxin production by the organism may allow GAS to spread across tissue planes and cause necrosis while evading containment by the maternal immune system in the form of a discrete abscess. Endometrial aspiration in addition to blood cultures may be a useful rapid diagnostic tool. Imaging may appear normal and should not dissuade the clinician from aggressive management. When suspected, invasive GAS infections should be treated emergently with fluid resuscitation, antibiotic administration, and source control. The optimal antibiotic regimen contains penicillin and clindamycin. Source control may require extensive wound or vulvar debridement, hysterectomy, or a combination of these, which may be life-saving. The benefit of immunoglobulins in management of puerperal GAS infections is unclear.

Creatine kinase as an indicator for hysterectomy in postpartum endomyometritis due to group A streptococci: a hypothesis illustrated by a case report

BACKGROUND

Puerperal group A streptococcus (GAS) infection, once the leading cause of postpartum sepsis, has been increasing again since the 1980s. Streptococcal toxic shock syndrome (STSS) is a serious complication characterized by rapidly spreading GAS infection, shock, and multiple organ failure. Immediate recognition and implementation of therapy is crucial for survival. Making informed decisions regarding surgical debridement, namely hysterectomy, based on clinical indicators is difficult for practitioners.

OBJECTIVES

This article discusses the potential role of creatine kinase in the decision-making process for treatment of STSS, particularly with regard to hysterectomy.

MATERIAL AND METHODS

A case report is presented. The literature was searched using the key words 'group A streptococcus', 'postpartum hysterectomy', 'creatine kinase', 'endomyometritis', and 'streptococcal toxic shock syndrome' in PubMed and the UptoDate database. Relevant articles published between 1991 and 2011 were evaluated.

CONCLUSION

Decisions regarding hysterectomy in STSS management are difficult. A rise in CK levels in the serum may indicate involvement of the myometrium and may be an important parameter in the difficult decision of hysterectomy when treating STSS.

Severe bacterial infections of the skin: uncommon presentations

Although most bacterial infections of the skin prove to be minor in nature, a few such dermatologic entities are significant, to the point of even being fatal. Their course can be extremely rapid and can lead to dreadful complications. The mortality rate is usually up to 30% to 50% and depends upon the type of infection, underlying disease, and immune status. Patients suffering them usually need to be hospitalized, sometimes in intensive care or burn units. They should be treated systemically with appropriate antimicrobial therapy plus aggressive supportive care. The two life-threatening skin infections which are most commonly experienced are toxin-mediated staphylococcal and streptococcal disorders; one could overlap the other. Several other related entities will also be discussed.

Group A Streptococcal Puerperal Sepsis with Retroperitoneal Involvement Developing in a Late Postpartum Woman: Case Report

Group A beta-hemolytic streptococci cause a wide range of infectious diseases such as pharyngitis, impetigo, rheumatic fever, and even septic shock. Group A streptococcal puerperal sepsis is uncommon today, but recent reports indicate a reemergence of virulent strains can cause toxic-mediated shock and multiple organ failure. We present a case report of a 29-year-old postpartum woman after cesarean section who presented group A streptococcal puerperal sepsis. Furthermore, we discuss the GAS strain in this patient and its relation with close contact among family members. The group A streptococci (GAS) were isolated from the patient's retroperitoneal fluid and from her husband's throat swab, respectively. Both isolates were shown to be identical: M type 1. It is well known that exotoxin A produced by M1 or M3 serotypes of the organisms plays a crucial role in streptococcal toxic shock syndrome (STSS). We conclude that in this patient, close contacts of persons with GAS appear to be at risk for colonization with identical strains of STSS-causing GAS such as M1 or M3 serotypes. Therefore, the appropriate antibiotic including antibiotic prophylaxis for close contact should be considered.