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Chest Infections |

A ‘GASsy’ Cavity in the Lung: Group A Streptococcal (GAS) Cavitary Pneumonia

Abhijeet Ghatol, MD; Jared Intaphan, MD
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Cedars Sinai Medical Center, Los Angeles, CA


Chest. 2013;144(4_MeetingAbstracts):174A. doi:10.1378/chest.1703672
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Abstract

SESSION TITLE: Infectious Disease Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: GAS are a known cause of erysipelas, impetigo and pharyngitis. Invasive GAS infection can cause pneumonia, necrotizing fasciitis and streptococcal toxic shock syndrome (STSS). Rarely have they been described to cause cavitary pneumonia, which is a unique feature of the case we present here.

CASE PRESENTATION: A 43 year-old male with diabetes mellitus presented with 5 day history of fever, sore throat, productive cough and neck rash. He was febrile,103°F, pulse 118/min, and blood pressure 109/75 mm Hg. Oral exam showed tonsillar swelling,erythema and a strawberry tongue. He had cervical adenopathy and skin over the neck had erythema and induration around strap muscles extending to the sternum. He had an erythematous, blanching maculopapular rash in the axillae and abdomen. Blood work showed leukocytosis (WBC:14.7) with bandemia (23%). Chest imaging showed a 4.5 x 5.2 cm right upper lobe cavitary lung lesion and mediastinal adenopathy. CT neck revealed severe inflammatory changes in the neck extending into the retropharynx and mediastinum and multiple loculated small fluid collections around the strap muscles. Bilateral jugular veins were patent. Vancomycin, piperacillin-tazobactam and clindamycin were started. Blood and sputum cultures resulted positive for group A,beta-hemolytic streptococci sensitive to penicillin. Sputum AFBx3, coccidioidomycosis & histoplasma serologies were negative. Vancomycin was discontinued and piperacillin-tazobactam was changed to Penicillin G IV. Clindamycin was continued for 2 weeks for its effect in decreasing GAS toxin. Though there was an initial concern for airway compromise he did not require intubation. He improved with antibiotic therapy with resolution of the neck rash & swelling. Follow up imaging showed decrease in cavity size. He was discharged home to complete a 4 week therapy with IV Ceftriaxone for the invasive GAS infection.

DISCUSSION: Severe illnesses related to group A streptococci manifest as necrotizing fasciitis, pneumonia, STSS, bacteremia and sepsis1. Risk factors for invasive GAS infection are diabetes, immunosuppression, cardiac disease and malignancy. Patients admitted to an ICU with GAS infections have high mortality rates with a direct correlation to APACHE II score, age, presence of STSS and number of organ failures1 Studies report mortality rates from invasive GAS infection from 13.7% to 40%. Our patient had evidence of invasive GAS disease presenting as pharyngitis,erysipelas, cavitary pneumonia and sepsis. He however had a less severe clinical course compared to patients who present with invasive illness. His diabetes was a risk factor for infection however his age and absence of STSS may have played a role in his favorable outcome.

CONCLUSIONS: GAS should be considered in the differential of cavitary pneumonia in the appropriate clinical setting.

Reference #1: Mehta S,et al.Morbidity and mortality of patients with invasive group A streptococcal infections admitted to the ICU.Chest 2006;130:1679-86

DISCLOSURE: The following authors have nothing to disclose: Abhijeet Ghatol, Jared Intaphan

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