We report a case of pseudomembranous tracheobronchitis causing central airway obstruction in a previously healthy 48-year-old man with severe septic shock and acute respiratory distress syndrome from Streptococcous pyogenes (Group A Strep).
A 48-year-old white male presented to the Emergency Department with a three-day history of sore throat, fever, and shortness of breath. On physical examination, the patient was toxic appearing. His rectal temperature was 35.5 degrees Celsius (95.7 degrees Fahrenheit), blood pressure was 94/53 mm Hg, pulse was 143 beats per minute, respirations were 30 breaths per minute, and oxygen saturation was 89% on room air. Initial examination was significant for diffuse erythema of the head and neck with prominent cervical lymphadenopathy, bilateral proptosis, tachycardia, diffuse inspiratory and expiratory wheezing, and dusky appearing extremities. Laboratory data were significant for neutropenia, thrombocytopenia, elevated creatinine, elevated liver enzymes, and lactic acidosis. Chest x-ray showed a patchy alveolar pattern. Admission computed tomography (CT) scan of the chest showed dense parenchymal consolidation of the lower lobes and scattered alveolar opacities of the upper lobes. The patient was intubated for impending respiratory failure, admitted to the intensive care unit, and treated for septic shock. Within 24 hours, blood cultures were positive for Streptococcus pyogenes. By day four, physical examination was notable for severe desquamation of the extremities. On day seven, he developed worsening oxygenation and ventilation. A CT scan of the chest showed persistent alveolar opacities, parenchymal consolidation, and evidence of mucous secretions within the trachea and mainstem bronchi bilaterally (Figures 1). The patient subsequently underwent diagnostic fiberoptic bronchoscopy revealing diffuse pseudomembranes involving the majority of the trachea and bilateral mainstem bronchi (Figure 2). There was near complete obliteration of the left main bronchus. Flexible bronchoscopic forceps were unsuccessful in removing the obstructing tissue. Airway patency was re-established when cryo-adhesion therapy was utilized to remove the pseudomembranes. The histo-pathologic findings were remarkable for large amounts of mucoid material with extensive hemorrhage and acute inflammation with varying amounts of fibrin. Herpes PCR was positive, but viral inclusions were not seen on the pathological specimen. The patient ultimately recovered and was discharged home.
Streptococcus pyogenes sepsis is a rare event, but the mortality is high due to a rapidly progressive course and multiorgan failure. Common manifestations of the infection include pharyngitis and cellulitis. It is also frequently reported in the obstetrics literature as puerperal infections. More serious presentations include the toxin-mediated diseases such as necrotizing fasciitis and toxic shock syndrome (TSS). (1) Pseudomembranous tracheobronchitis has been reported in association with endotracheal intubations, smoke inhalation injury, and infections such as Aspergillus spp., methicillin-resistant Staphylococcus aureus, Bacillus cereus, Corynebacterium diphtheriae, viruses and rarely inflammatory bowel disease. (2) Several of the infectious etiologies that have been associated with pseudomembranes are toxin producing organisms. The severe desquamation that our patient experienced coincided with the endotracheal mucosal sloughing. This was thought to be a consequence of toxin production by S. pyogenes. Herpes simplex is a frequent isolate from airway samples obtained during respiratory failure. In our case, no viral inclusions were noted on pathologic specimens and were likely an incidental finding.
Our patient suffered from central airway obstruction due to pseudomembranous tracheobronchitis associated with TSS. He was successsfully treated with bedside therapeutic bronchoscopy. Upon review of the literature, this is the first reported case of pseudomembranous tracheobronchitis associated with S. pyogenes and TSS.
Marcia Henderson, No Financial Disclosure Information; No Product/Research Disclosure Information