Chest Infections: Student/Resident Case Report Poster - Chest Infections I |

Necrotizing Pneumonia and Toxic Shock Caused by Group a Streptococcus: A Case Report FREE TO VIEW

Andrew Cheng, MD; Janine Vintch, MD
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Harbor-UCLA, Laguna Hills, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):163A. doi:10.1016/j.chest.2016.08.172
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Cases of community acquired pneumonia (CAP) have been estimated to range from 4 to 5 million per year with 25% requiring hospitalization.1 While rare, necrotizing pneumonia can be a severe complication that is often seen from Staph aureus and Pneumococcal disease. Invasive group A streptococcal (GAS) infection is not a typical cause of CAP and accounts for a small percentage of cases. However, GAS pneumonia should always be considered given its high mortality, particularly when associated with streptococcal toxic shock syndrome (STSS).

CASE PRESENTATION: A 46-year-old female with diabetes was brought to the ED with cough and pleuritic chest pain. On physical exam she was febrile to 38.7C, tachycardic to 120, tachypneic to 30 with desaturations on room air to 80%. She was intubated for hypoxic respiratory failure. Initial labs were remarkable for blood glucose of 571, leukocytosis to 17.1 with 43% bands, Cr of 2.05 and ABG pH of 7.14. Admission CXR was notable for right pneumothorax and chest tube was placed. A subsequent CT scan showed pneumomediastinum with bilateral pneumothoraces, bilateral posterior opacities, and a right cavitary lesion. She became hypotensive and required vasopressors. Broad spectrum antibiotics were started with vancomycin, meropenem, levofloxacin, and fluconazole. Blood, respiratory, and pleural fluid cultures were sent with admission pleural fluid growing Streptococcus pyogenes. Given positive cultures, shock, ARDS, and renal dysfunction a diagnosis of STSS was made. Hemodialysis was initiated for acidemia and worsening renal failure. She continued to deteriorate and eventually pulse was lost and patient expired on hospital day 20.

DISCUSSION: This case demonstrates that while rare, invasive GAS infections can present with severe necrotizing pneumonia as a primary cause of STSS. Observational studies estimate invasive GAS infections account for 9,000-11,000 cases per year with a case-fatality rate of 11-14%.2 Pneumonia accounts for a small proportion (11%)3, and studies are often limited to case reports. However, there is growing evidence of an increase in GAS pneumonia with one study showing a doubling in incidence over a 7 year period.3 These cases are often associated with chronic medical conditions. Like this patient, up to 61% of patients have an underlying disease ranging from lung disease (21%) to diabetes (17%).3

CONCLUSIONS: In conclusion, it is important to think of GAS as a causative agent in chronically ill patients who present with pneumonia, particularly when considering its mortality of 38%.3 Once the diagnosis is made, source control and antibiotics are of utmost importance. Complications such as pneumothorax should be treated accordingly with chest tube placement, and surgery may be considered in severe cases.

Reference #1: Hoyert D et al. Natl Vital Stat Rep. 2006;54(13):1-120

Reference #2: Cohemn-Poradosu R et al. Clin Infect Disease. 2007;45(7):863-5

Reference #3: Muller MP et al. Arch Intern Med. 2003;163(4):467-72

DISCLOSURE: The following authors have nothing to disclose: Andrew Cheng, Janine Vintch

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