Post-partum streptococcal toxic shock syndrome associated with necrotizing fasciitis

Abstract

We report a fatal case of post-partum streptococcal toxic shock syndrome in a patient who was previously healthy and had presented to the emergency department with an extensive blistering ecchymotic lesions over her right buttock and thigh associated with severe pain. The pregnancy had been uncomplicated, and the mode of delivery had been spontaneous vaginal delivery with an episiotomy. She was found to have septicemic shock requiring high inotropic support. Subsequently, she was treated for necrotizing fasciitis, complicated by septicemic shock and multiple organ failures. A consensus was reached for extensive wound debridement to remove the source of infection; however, this approach was abandoned due to the patient’s hemodynamic instability and the extremely high risks of surgery. Both the high vaginal swab and blister fluid culture revealed Group A beta hemolytic streptococcus infection. Intravenous carbapenem in combination with clindamycin was given. Other strategies attempted for streptococcal toxic removal included continuous veno-venous hemofiltration and administration of intravenous immunoglobulin. Unfortunately, the patient’s condition worsened, and she succumbed to death on day 7 of hospitalization.

Another Fatality Due to Postpartum Group A Streptococcal Endometritis in the Modern Era

“…Multiple streptococcal exotoxins act as superantigens to stimulate T cell activation eventually leading to watershed induction of both T cell lymphocytes and monocytes [8]. A breach of the mucosal barrier during labor and the postpartum period can result in the entry of streptococci into deeper tissues, and eventually the bloodstream, which might lead to streptococcal TSS [9].…”

“…As soon as sepsis is suspected, the patient should be started on broad-spectrum antibiotics along with supportive management as indicated. Once GAS infection is confirmed, antibiotics should be escalated to high-dose penicillin combined with clindamycin [9]. Clindamycin is used due to its ability to suppress the synthesis of penicillin-binding proteins and bacterial exotoxins.…”

“…Also, it has been shown to inhibit bacterial toxin synthesis and promote phagocytosis [12]. Source control and urgent intervention such as surgical exploration, debridement, and rarely hysterectomy are of paramount importance and should not be overlooked in cases with refractory shock [9]. The successful use of intravenous immunoglobulin for exotoxin neutralization in treating streptococcal TSS remains debatable [13].…”

The Shock of Strep: Rapid Deaths Due to Group a Streptococcus

“…Group A beta-hemolytic strep is a non-discriminatory organism. Infections occur at any age, with more severe illnesses affecting the extremes of age (less than 2 and greater than 65) (5,6,8,9). Most patients become infected by human to human transmission via respiratory droplets (4,5).…”

“…Every patient who proceeds to a severe or invasive infection will develop a characteristic high fever at some point during the illness (8). Patients with soft tissue infection will begin with pain in the affected area that grows out of proportion to the visual appearance of the infection (6,16). Leukocyte count can be quite variable (8).…”