Purpose: To review the literature on group A streptococcal toxic shock syndrome, (STSS). Data source: Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also searched using key words intravenous immunoglobulin, (IVIG) and group A streptococcus, (GAS); and group A streptococcus and antibiotic therapy. Other references were included in this review if they addressed the history, microbiology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed were also considered. Articles on the foregoing topics were included regardless of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically searched. Principal findings: Reports of invasive GAS infections have recently increased. Invasive GAS infection is associated with a toxic shock syndrome, (STSS), in 8 -14% of cases. The STSS characteristically results in shock and multi-organ failure soon after the onset of symptoms, and is associated with a mortality of 33 -81%. Many of these patients will require extensive soft tissue debridement or amputation in the operating room, on an emergency basis. The extent of tissue debridement required is often underestimated before skin incision. Conclusions: Management of STSS requires volume resuscitation, vasopressor/inotrope infusion, antibiotic therapy and supportive care in an intensive care unit, usually including mechanical ventilation. Intravenous immunoglobulin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic management of patients with septic shock.Objectif: Passer en revue la documentation sur le syndrome de choc toxique streptococcique de groupe A (SCTS). Sources: Des recherches ont été menées dans Medline et EMBASE en utilisant les mots-clés: group A streptococcal toxic shock syndrome, seul et en combinaison avec anesthesia; septic shock, combiné avec anesthesia. Dans Medline, nous avons aussi utilisé les entrées intravenous immunoglobulin (immunoblobuline intraveineuse, IGIV) et group A streptococcus (streptocoque du groupe A, SGA) et antibiotic therapy. Nous avons retenu d'autres références qui concernaient l'histoire, la microbiologie, la physiopathologie, l'incidence, la mortalité, la présenta-tion et le traitement des infections invasives de SGA. Les références pertinentes provenant des articles révisés ont aussi été conservées. Les articles concernant les sujets déjà cités ont été retenus sans tenir compte du type d'é-tude. On a exclu les études d'autres langues que l'anglais. La documentation sur l'efficacité de l'IGIV et sur l'antibiothérapie optimale a été spécialement recherchée. Constatations principales : Les articles sur les infections envahissantes de SGA ont récemment augmenté. L'infection invasive de ...

No abstract

The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoningPurpose: This report describes a case of organophosphate intoxication refractory to atropine in which glycopyrrolate was used to reduce cholinergic symptoms, and describes the development of intermediate syndrome, an uncommon subacute complication of organophosphate poisoning. Clinical features: A 44-yr-old woman presented in cholinergic crisis following malathion ingestion. Treatment was initiated with atropine and pralidoxime. Despite clinical signs of adequate atropinisation, the patient continued to have profuse bronchorrhoea, which resolved with glycopyrrolate. During her course in the intensive care unit, she displayed a subacute deterioration in neuromuscular and mental status with decrement-increment phenomenon on electromyography consistent with intermediate syndrome. The patient eventually made a complete recovery. Conclusion: This case report describes the successful use of glycopyrrolate in organophosphate intoxication and the development of the intermediate syndrome, characterised by onset of weakness of neck flexors, proximal limb muscles, and respiratory muscles within one to four clays after poisoning. Recognition of the syndrome is important in light of the potential for respiratory depression requiring ventilatory support.Objectif : Cette observation d&rit un cas d'intoxication aux organophosphor& r6fractaire ~ ratropine o6 le glycopyrrolate a ~t~ utilis~ pour diminuer les sympt6mes cholinengiques, et d&rit aussi le d~veloppement d'un syndrome interm~diaire, une complication subaigu~ non fr~quente de I'empoisonnement aux organophosphor~s. l~,l~ments cliniques : Une femme de 44 ans se pr&ente en crise cholinergique suite ~ I'ingestion de malathion. On d~bute le traitement ~. ratropine et ~ la pralidoxime. Malgr~ des signes cliniques d'atropinisation adequate, la patiente continue ~ pr&enter une bronchorrh~e profuse, qui rentre dans I'ordre avec le glycopyrrolate. Durant son s~jour aux soins intensifs, elle pr&ente une d&&ioration subaigua de la fonction neuromusculaire et mentale avec ph~nom~ne incr~mentiel-d&r~mentiel ~ I'~lectromyographie, compatible avec un syndrome interm~-diaire. Cette patiente va &entuellement r&up&er compl&ement. Conclusion : Cette observation ~ propos d'un cas d&rit I'utilisation avec succ& du g!ycopyrrolate dans I'intoxication aux organophosphor& et la survenue d'un syndrome interm~diaire caract&is~ par rapparition de faiblesse au niveau des fl&hisseurs du cou, des muscles proximaux des membres et des muscles respiratoires survenant dans un d~lai de un ~ quatre jours apr& I'intoxication. Lidentification de ce syndrome est importante ~ cause de son potentiel d'insuffisance respiratoire n&essitant un support ventilatoire.