SESSION TITLE: Infectious Disease Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Streptococcal toxic shock syndrome (STSS) is a rapidly fatal disease causing hypotension with multi organ dysfunction (MODS) early in the course of infection which by definition is caused by Group A streptococcus (GAS).1 We describe a case of STSS in which the causative organism was not a GAS.
CASE PRESENTATION: A 71-year-old woman with hepatitis C and primary biliary cirrhosis had sudden onset of slurred speech & left arm /facial numbness. She had some swelling of her leg that occurred a few days ago after a fall. On admission her vitals were; temperature 97.7 F; heart rate 107/min; blood pressure 109/64 mm Hg; respirations 24/min. Physical exam was significant for bilateral mottling on the flanks and legs. The white cell count was 3.4 Thou/mm3 , platelets 44 Thou/mm3; creatinine 2.36 mg/dL (Baseline of 1 mg/dL ); blood urea nitrogen 50 mg/dL ; bicarbonate 14 meq/L; INR 1.88; AST 275 IU/L H; total bilirubin 4.1 mg/dL; lactate 12.2 mmol/L and myoglobin 58631 ng/mL. Glucose was 53 mg/dl and the patient’s speech improved after administration of dextrose. The CT head, chest, and abdomen were unremarkable. Fluid resuscitation was initiated, blood cultures were drawn, and the patient was started on Vancomycin and Zosyn for suspected sepsis. The VBG showed pH of 7.04, Co2 of 35 and bicarbonate of 11 meq/L. Her condition rapidly deteriorated 6 hours after admission with her lactate increasing to 15.3 mmol/L & myoglobin increased to 123044 ng/mL . She got drowsy, hemodynamically unstable and was intubated. Pressors and bicarbonate drip were initiated. During this time, the development of multiple large reddish-pink areas of ecchymosis with bullae on her lower extremities, flanks, and groin were noted (Figure 1). Patient expired before surgery could be performed and the time from presentation to the time of death was 14 hours. The blood and bullae fluid cultures grew Streptococcus dysgalactiae equisimilis (SDE). Postmortem pathology determined cause of death was SDE sepsis with loculated pericarditis but no necrotizing fasciitis was seen.
DISCUSSION: SDE is a rare cause of STSS which typically affects elderly or immunocompromised patients and only a few cases have been described in the literature (Table 1). Our patient met criteria for STSS which caused rapid shock and MODS (renal dysfunction, coagulopathy, liver involvement, and a generalized erythematous macular rash).
CONCLUSIONS: Group G Streptococci is an unrecognized but lethal cause of Streptococcal TSS
Reference #1: Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections. JAMA 1993; 269:390-391
DISCLOSURE: The following authors have nothing to disclose: Katie Young, Faraz Khan Luni, Youngsook Yoon
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