Streptococcal toxic shock syndrome in the intensive care unit

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.

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.

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.

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.

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.

Morbidity and mortality in critically ill patients with invasive group A streptococcus infection: an observational study

Background

Group A streptococci (GAS) are known to cause serious invasive infections, but little is known about outcomes when patients with these infections are admitted to intensive care. We wanted to describe critically ill patients with severe sepsis or septic shock due to invasive GAS (iGAS) and compare them with other patients with severe sepsis or septic shock.

Methods

Adult patients admitted to a general intensive care unit (ICU) in Sweden (2007–2019) were screened for severe sepsis or septic shock according to Sepsis 2 definition. Individuals with iGAS infection were identified. The outcome variables were mortality, days alive and free of vasopressors and invasive mechanical ventilation, maximum acute kidney injury score for creatinine, use of continuous renal replacement therapy and maximum Sequential Organ Failure Assessment score during the ICU stay. Age, Simplified Acute Physiology Score (SAPS 3) and iGAS were used as independent, explanatory variables in regression analysis. Cox regression was used for survival analyses.

Results

iGAS was identified in 53 of 1021 (5.2%) patients. Patients with iGAS presented a lower median SAPS 3 score (62 [56–72]) vs 71 [61–81]), p <  0.001), had a higher frequency of cardiovascular cause of admission to the ICU (38 [72%] vs 145 [15%], p <  0.001) and had a higher median creatinine score (173 [100–311] vs 133 [86–208] μmol/L, p <  0.019). Of the GAS isolates, 50% were serotyped emm1/T1 and this group showed signs of more pronounced circulatory and renal failure than patients with non-emm1/T1 (p = 0.036 and p = 0.007, respectively). After correction for severity of illness (SAPS 3) and age, iGAS infection was associated with lower mortality risk (95% confidence interval (CI) of hazard ratio (HR) 0.204–0.746, p <  0.001). Morbidity analyses demonstrated that iGAS patients were more likely to develop renal failure.

Conclusion

Critically ill patients with iGAS infection had a lower mortality risk but a higher degree of renal failure compared to similarly ill sepsis patients. emm1/T1 was found to be the most dominant serotype, and patients with emm1/T1 demonstrated more circulatory and renal failure than patients with other serotypes of iGAS.

Toxic Shock Syndrome after Surgery: Case Presentation and Systematic Review of the Literature

Supplemental Digital Content is available in the text.

Toxic shock syndrome (TSS) is an underrecognized but highly fatal cause of septic shock in postoperative patients. Although it may present with no overt source of infection, its course is devastating and rapidly progressive. Surgeon awareness is needed to recognize and treat this condition appropriately. In this paper, we aim to describe a case of postoperative TSS, present a systematic review of the literature, and provide an overview of the disease for the surgeon.

Redundant Anaerobic Antimicrobial Prescriptions in German Acute Care Hospitals: Data from a National Point Prevalence Survey

Despite limited indications, redundant anaerobic antimicrobial prescriptions (RAAPs) are frequent. The objective of this study was to assess the prevalence and characteristics of RAAPs in German acute care hospitals. In a retrospective data analysis, antimicrobial prescriptions from a point prevalence survey on antimicrobial use in German acute care hospitals in 2016 were analyzed and RAAPs were identified. RAAPs were defined as a patient simultaneously receiving any of the following combinations: Penicillin/beta-lactamase inhibitor (PenBLI) plus clindamycin; PenBLI plus metronidazole; PenBLI plus moxifloxacin; PenBLI plus carbapenem; carbapenem plus clindamycin; carbapenem plus metronidazole; carbapenem plus moxifloxacin; clindamycin plus metronidazole; clindamycin plus moxifloxacin; and metronidazole plus moxifloxacin. Data from 64,412 patients in 218 hospitals were included. Overall, 4486 patients (7%) received two or more antimicrobials. In total, 441 RAAP combinations were identified. PenBLI plus metronidazole was the most common anaerobic combination (N = 166, 38%). The majority of RAAPs were for the treatment of community-acquired (N = 258, 59%) infections. Lower respiratory tract infections (N = 77; 20%) and skin/soft tissue infections (N = 76; 20%) were the most frequently recorded types of infections. RAAPs are common in German hospitals. Reducing redundant antimicrobial coverage should be a key component of future antimicrobial stewardship activities.

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.

Group A Streptococcal Infection During Pregnancy and the Postpartum Period

Group A Streptococcus, the causative organism for "childbed fever," continues to pose a threat to women during pregnancy and the postpartum period, despite advances in hygiene and the development of antibiotic therapy. This resilient bacterium has resurfaced with intensified virulence, and, for reasons not entirely clear, causes severe disease in some women. Sepsis and toxic shock syndrome caused by Group A Streptococcus contribute to the alarming rates of maternal morbidity and mortality in the United States. Early recognition of the subtle signs and symptoms of sepsis is critical to decrease the risk for mortality; however, early signs can be elusive during the perinatal period because of the physiologic changes of pregnancy. Care management requires a coordinated, collaborative, multidisciplinary team approach. Sepsis is a clinical emergency, and health care providers need to respond as a well-prepared team.

Weird and wonderful ICU cases: Unusual causes of shock

During their practice, intensivists are ought to face challenging cases that are rare. Intensivists need to be aware of the rare causes of shock beyond common presentations. In each category of shock, there are rare causes that require prompt identification and management. Certain clues in the patient's presentation might point to those rare causes.

Classically shock is classified into: distributive, hypovolemic, cardiogenic, and obstructive. In this era of bedside point-of-care ultrasound, intensivists are able to promptly identify the cause of shock and institute a resuscitation plan. However, there are cases when the diagnosis is still obscure and the cause of shock is not easily identified. For example, in a study of patients admitted with presumed septic shock, 7.4% had no identified cause of shock and 11% had sepsis mimickers.¹

Hypovolemic shock occurs secondary to a reduction in the effective circulating volume secondary to fluid loss or third spacing. A rare cause of hypovolemic shock is idiopathic capillary leak syndrome (Clarkson Syndrome).² The syndrome is characterized by recurrent episodes of rapidly progressive generalized edema, shock, renal failure and high hematocrit. The episode usually resolves in 3-7 days where the capillary leak resolves and a phase of pulmonary edema occurs. Several treatment options such as intravenous immunoglobulin (IVIG) and aminophylline were used in case reports.³

Vasodilatory shock occurs secondary to peripheral vasodilation and decrease in blood flow. It occurs as part of the systemic inflammatory response syndrome for which sepsis, acute pancreatitis, acute liver failure, and major trauma are common causes. Rare causes that need to be considered include: hemophagocytic lymphohistiocytosis (HLH), systemic mastocytosis, and toxic shock syndrome.

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by macrophage activation and engulfment of hemopoetic cells which leads to pancytopenia. It is also characterized by cytokines storm that lead to a vasodilatory shock, multi-organ failure, and acute respiratory distress syndrome (ARDS). The most common triggers are infection, malignancy, and autoimmune diseases. Pointers to this diagnosis in the intensive care unit include: pancytopenias, hypofibrinogenemia, high triglycerides, and high ferritin. Treatment necessitates treating the underlying cause as well as using immune modifying therapies.⁴

Systemic mastocytosis is a rare cause of recurrent anaphylaxis shock. It results from the accumulation of mast cells in tissues and can present with anaphylaxis and vascular collapse. An important clue to the diagnosis is the presence of urticarial pigmentosa and the absence of an allergen history.⁵

Toxic shock syndrome is a unique cause of sepsis. It is caused by a pre-formed toxin produced by Staphylococcus aureus and Streptococcus pyrogenes. The clue to the diagnosis include the rapid onset after the precipitating factor, erythroderma, and skin desquamation. Treatment includes IVIG and Clindamycin.⁶

Necrotizing skin and soft-tissue infections in the intensive care unit

BACKGROUND

Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission.

OBJECTIVES

To review all aspects of care for a critically ill individual with NSTI.

SOURCES

Literature search using Medline and Cochrane library, multidisciplinary panel of experts.

CONTENT

The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial.

IMPLICATIONS

Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.

The Role of Streptococcal and Staphylococcal Exotoxins and Proteases in Human Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) are critical clinical conditions characterized by extensive necrosis of any layer of the soft tissue and systemic toxicity. Group A streptococci (GAS) and Staphylococcus aureus are two major pathogens associated with monomicrobial NSTIs. In the tissue environment, both Gram-positive bacteria secrete a variety of molecules, including pore-forming exotoxins, superantigens, and proteases with cytolytic and immunomodulatory functions. The present review summarizes the current knowledge about streptococcal and staphylococcal toxins in NSTIs with a special focus on their contribution to disease progression, tissue pathology, and immune evasion strategies.