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

An Innocuous Appearing Thumb Lesion Leading to High Grade Shock and Multiorgan Failure FREE TO VIEW

Apurva Pandey, MD; Shawhin Karimi, MD; Steven Keller, MD; Brad Butcher, MD
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University of Pittsburgh Medical Center, Pittsburgh, PA

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

Chest. 2016;150(4_S):403A. doi:10.1016/j.chest.2016.08.416
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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 A streptococcus (GAS) is a common cause of uncomplicated cellulitis and is typically managed with a short course of oral antibiotics. For unclear reasons, certain susceptible individuals can suffer from aggressive soft tissue infections that manifest as necrotizing fasciitis, while others can experience toxin-mediated shock syndromes that result from minor-appearing skin injuries. We present the case of a patient who experienced streptococcal toxic shock syndrome (TSS) that progressed to multi-system organ failure resulting from a small purpuric thumb lesion.

CASE PRESENTATION: A 49-year-old male with compensated alcoholic cirrhosis presented with a painful, swollen left thumb, generalized abdominal pain with diarrhea, and lightheadedness. On examination, he was afebrile, hypotensive with a blood pressure of 60/40 mmHg, and hypoxemic, with an oxygen saturation of 88% while breathing ambient air. His left thumb was swollen, and a 1 cm purpuric eschar was identified on the lateral surface with no known antecedent trauma. Laboratory studies were notable for acute kidney injury (AKI), lactic acidosis, elevated transaminases, hyperbilirubinemia, and a marked leukocytosis with left shift. Despite aggressive volume resuscitation and initiation of broad spectrum antibiotics, he rapidly developed profound shock requiring administration of epinephrine, norepinephrine, and vasopressin; respiratory failure requiring intubation; anuria requiring continuous renal replacement therapy; and decompensated cirrhosis. Incision and drainage of the left thumb was performed, and cultures grew GAS; blood cultures remained sterile. Following debridement and narrowing of his antibiotics to ampicillin-sulbactam and clindamycin, his hypotension and AKI resolved, his tests of liver function improved, and he was successfully extubated and ultimately discharged home.

DISCUSSION: GAS is an aerobic, Gram-positive bacterium that releases pyrogenic exotoxins, which can behave as super-antigens and trigger a massive release of inflammatory cytokines. Many factors, including trauma, use of NSAIDS, and co-morbid diabetes and alcoholism, are associated with severe GAS infections. In a case series of 67 patients with GAS TSS, skin was the primary site of infection in the majority of cases, but this was not recognized in 37% of them.1 Physicians should be mindful of GAS TSS as an etiology of shock in patients otherwise lacking an identified source of infection.

CONCLUSIONS: Given the lack of bacteremia and systemic infection, the profound hypotension and multisystem organ failure our patient experienced shows the potentially devastating effects of infections with toxin-producing bacteria. In patients with severe sepsis, even seemingly small findings, such as an ecchymotic thumb, must be critically evaluated as potential sources of infection.

Reference #1: Francis J, Warren RE. Streptococcus pyogenes bacteremia in Cambridge—a review of 67 episodes. Q J Med. 1988; 68(256):603

DISCLOSURE: The following authors have nothing to disclose: Apurva Pandey, Shawhin Karimi, Steven Keller, Brad Butcher

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