Critical Care: Student/Resident Case Report Poster - Critical Care II |

Refractory Toxic Shock-Like Syndrome From Group C Streptococcus Dysgalactiae Ssp. Equismilis Endocarditis and IVIG as Salvage Therapy FREE TO VIEW

Marjan Islam, MD; Jerry Altshuler, PharmD; Gianluca Torregrossa, MD; Dennis Karter, MD
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Mount Sinai Beth Israel, New York, NY

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

Chest. 2016;150(4_S):397A. doi:10.1016/j.chest.2016.08.410
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Group C streptococci (GCS) are gram-positive organisms not uncommonly found as colonizers of the human respiratory, gastrointestinal, and genital tracts. As pathogens, infections can range from harmless superficial skin infections to invasive disease such as meningitis, endocarditis, and streptococcal toxic shock-like syndrome (TSLS). Despite appropriate antibiotics, mortality remains exceedingly high in some invasive disease. We present a case of successful IVIG therapy for refractory GCS TSLS.

CASE PRESENTATION: A 37 year-old male presented with a 2 week history of flu-like symptoms. Initial assessment disclosed fever to 101oF, severe thrombocytopenia, leukocytosis with neutrophilia, and acute renal failure. Blood cultures grew Streptococcus dysgalactiae ssp. equismilis (SDSE), and TEE revealed a 1.6cm tricuspid valve vegetation. His EKG was noteable for 1st degree AV block, which eventually progressed to a type II 2nd degree block with occasional complete block. With concern for infectious spread to the conduction system, the patient was taken emergently to the OR for radical debridement of the endocarditis. Despite appropriate antibiotics, repeat TEE performed 5 days post-op revealed a new mitral valve vegetation with perforations in the anterior leaflets. He was again taken emergently to the OR, requiring extensive reconstruction of the cardiac skeleton following a repeat debridement. Post-operatively, the patient became profoundly hypotensive, and spiraled into a seemingly refractory vasoplegic shock. Despite multiple pressors, he remained hypotensive, and IVIG was attempted as salvage therapy. Remarkably, his pressor requirements diminished as hemodynamics normalized over the following 2 days. An extensive infectious work-up was pursued prior to discharge, but all remaining cultures and serology returned negative.

DISCUSSION: The pathogenicity of invasive SDSE lies in its ability to activate massive T-cell proliferation through superantigens, propagating a cytokine storm and precipitating vasoplegic shock in its host. While remaining universally susceptible to penicillins, adjunctive therapy with IVIG has been proposed as mortality rates remain high despite appropriate antibiotics. IVIG has been shown to modulate a dysregulated inflammatory response by lowering bacterial mitogenicity, and expression of inflammatory cytokines like IL-6 and TNF-α. Emerging evidence indicate IVIG may also contain superantigen-neutralizing antibodies, suggesting passive immunization through immunoglobulin therapy may be of utility in those lacking neccessary antibodies against important virulence factors.

CONCLUSIONS: IVIG may serve as a novel adjunctive therapy for streptococcal TSLS, especially as emerging pathogens like SDSE are becoming increasingly recognized, where clinical experience remains limited.

Reference #1: Brandt C., Spellerberg B. Human Infections Due to Streptococcus dysgalactiae Subspecies equisimilis. Clin Infect Dis. 2009 49 (5):766-772.

DISCLOSURE: The following authors have nothing to disclose: Marjan Islam, Jerry Altshuler, Gianluca Torregrossa, Dennis Karter

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