Streptococcal toxic shock syndrome / 中华实用儿科临床杂志

Streptococcal toxic shock syndrome (STSS) is a Group A Streptococcus (GAS) induced invasive infectious disease, which is characterized by abrupt onset and rapid progression with a high mortality rate.With the wide application of antimicrobial agents, the incidence of GAS infections has been substantially reduced.Nevertheless, STSS usually causes shock and multiple organ failure at the early stage of its clinical process, and the clinical symptoms are non-specific.Therefore, early identification, timely anti-infection and symptomatic treatment are particularly critical.Clinicians should pay high attention to the disease.

Síndrome de choque tóxico por Streptococcus pyogenes en un hospital de la Ciudad de México / Toxic shock syndrome caused by Streptococcus in a hospital from the Mexico City / Síndrome de choque tóxico por Streptococcus pyogenes em um hospital da Cidade do México

Resumen: El síndrome de choque tóxico por Streptococcus se describió por primera vez en 1978 por Todd y su equipo. Éste incluye datos de hipotensión, disoxia celular, aislamiento de Streptococcus pyogenes, así como la inclusión de dos o más de los siguientes criterios: síndrome de dificultad respiratoria aguda, insuficiencia renal, anormalidad hepática, coagulopatía y erupción cutánea con descamación. Es una enfermedad relativamente rara entre niños y adultos; representa una alta mortalidad, la cual oscila de 23 al 70%. En más de la mitad de los casos, se desconoce la causa de entrada de este patógeno al torrente sanguíneo, aunque los pacientes con alcoholismo, en los extremos de la vida, con comorbilidades (como enfermedad renal crónica, insuficiencia hepática y leucemias) y que hayan sido sometidos a esplenectomía son más susceptibles al contagio y a infecciones severas. En los pacientes que desarrollan infecciones de tejidos blandos profundos, como fascitis necrosante o infección intrauterina, el dolor severo es el síntoma inicial más frecuente.

Abstract: Streptococcal toxic shock syndrome was first described by Todd and collaborators in 1978, this syndrome includes hypotension, traces of cellular dysoxia, isolation Streptococcus pyogenes; as well as two or more of the following criteria: acute respiratory distress syndrome, renal failure, liver abnormality, coagulopathy, skin rash with necrosis flaking of soft tissues. It is a relatively rare disease among children and adults, representing a high mortality ranging from 23 to 70%. In more than half of the cases the cause of entry of this pathogen into the bloodstream is unknown, although patients with alcoholism, on the edge of death, with splenectomy, with comorbidities (chronic kidney disease, liver failure, leukemia) are more susceptible to infection, to acquire severe infections and shock. Cutaneous infections usually are followed by minor skin irritations (insect bites), 20% of the cases experience a flu-like syndrome (fever, chills, myalgia and diarrhea). In patients who develop deep soft tissue infections such as necrotizing fasciitis or intrauterine infection, the severe pain is the most common initial symptom of streptococcal TSS.

Resumo: A síndrome do choque tóxico estreptocócico foi descrita pela primeira vez por Todd et al em 1978, incluindo dados sobre hipotensão, disxia celular, isolamento de Streptococcus pyogenes, bem como 2 ou mais dos seguintes critérios: síndrome do desconforto respiratório agudo, insuficiência renal, anormalidade hepática, coagulopatia, erupção cutânea com descamação. É uma doença relativamente rara em crianças e adultos, representa uma alta mortalidade que varia de 23 a 70%. Em mais da metade dos casos, a causa desse patógeno na corrente sanguínea é desconhecida, embora pacientes com alcoolismo, extremos da vida, com esplenectomia e comorbidades (como doença renal crônica, insuficiência hepática, leucemia) sejam mais suscetíveis à infecção e infecções graves. Em pacientes que desenvolvem infecções profundas dos tecidos moles, como fasceíte necrozante ou infecção intra-uterina, a dor intensa é o sintoma inicial mais frequente.

Streptococcal toxic shock syndrome in children: one case report and literature review / 中国感染与化疗杂志

Objective To investigate the clinical manifestations, treatment and prognosis of streptococcal toxic shock syndrome (STSS) in children. Methods One case of STSS was reported in a child who was admitted to Children's Hospital of Fudan University. Search terms such as "streptococcal toxic shock syndrome", "children" and "case report" were used to identify relevant reports from PubMed database, as well as Chinese databases including Chongqing VIP, Wanfang, and China National Knowledge Infrastructure for further review. Results The patient in this report was a 11-year-old female. The main clinical manifestations were fever, red, swelling, and pain in the right lower extremity, associated with impaired walking and hypotension. Imaging examination suggested diffuse abnormal signals in the soft tissue of right thigh. Group A Streptococcus (namely Streptococcus pyogenes) was isolated from the puncture fluid. The patient was improved after active shock-correcting and anti-infective treatment. A total of 6 STSS cases were identified from Chinese databases between January 1, 1996 and May 1, 2017. All the 7 cases (including this one, 4 males and 3 females, 15 months to 13 years of age) reported fever and skin rashes, and rapidly progressed to shock. Respiratory failure was reported in 4 cases and supported with a ventilator. Three patients died, including 2 within 24 hours after hospitaladmission. A total of 38 STSS cases (40 days to 18 years of age) were identified from PubMed database. The main clinical manifestations of these cases were respiratory tract or digestive tract symptoms, and skin and soft tissue infection. In addition, chickenpox was found in 3 cases, Kawasaki disease in 2 cases, neonatal bullous impetigo, pancreatitis, infectious mononucleosis, and lymphohistiocytosis in one case each. Of the 38 patients, 22 survived and 16 died. Conclusions STSS is a rare and severe form of invasive streptococcal infection in children. The early manifestations are not specific, which may be mistaken for upper respiratory tract infection, gastrointestinal dysfunction symptoms, skin and soft tissue infection, or muscle and joint disorder, or even similar to or associated with Kawasaki disease. But rapid progression to shock and multiple organ failure of STSS pose a serious threat to children. Pediatricians should keep alert on STSS. Early identification, timely diagnosis, and adequate treatment are key to improving patient outcome.

Streptococcal toxic shock syndrome caused by Streptococcus pyogenes: a retrospective study of 15 pediatric cases / 中华儿科杂志

Objective@#To improve the understanding of clinical characteristics of streptococcal toxic shock syndrome (STSS) caused by Streptococcus pyogenes (S. pyogenes) in children.@*Methods@#A retrospective study was conducted to analyze the clinical data of STSS caused by S. pyogenes (culture-confirmed) in 7 tertiary hospitals during 2010—2017 in China. Clinical and laboratory data were collected by reviewing the medical records.@*Results@#Fifteen cases of STSS, including 9 males, were confirmed and the ages of the patients ranged from 6 months to 15 years, with median age of 3 years. All cases had the positive blood culture for S. pyogenes and only 3 cases had short course of β-lactam treatment before blood culture. Medical evaluation was initiated within (5.1±4.6) days after symptom onset. All patients had fever, and 13 patients had multiple organ dysfunction and 10 patients had disseminated intravascular coagulationl (DIC). Twelve cases had severe pneumonia with or without skin and (or) soft tissue infections. Underlying conditions included giant hemangioma of the skin in 2 patients and varicella in 1 patient. All isolated strains in 14 cases were sensitive to penicillin G, ceftriaxone/cefotaxime, vancomycin, but 12 and 13 isolates were resistant to clindamycin and erythromycin, respectively. Eight patients died, and 5 of them died within 24 hours after admission. One patient was lost to follow-up after intended discharge against medical advice.@*Conclusion@#STSS caused by S. pyogenes in children is a severe syndrome with rapid clinical progression and high mortality rate, and thus the pediatricians should be aware of STSS and immediately initiate aggressive treatment for the suspected cases.

A Case of Streptococcal Toxic Shock Syndrome Clinically Presenting with Purpura Fulminans / 대한피부과학회지

Purpura fulminans is a term that describes an acute, often lethal, syndrome of hemorrhagic necrosis of the skin, due to dermal vascular thrombosis associated with vascular collapse and disseminated intravascular coagulation. Although it is seen in several clinical settings, it occurs most commonly in patients with acute, current infection. The causative organisms include meningococci, Gram-negative bacilli, staphylococci, streptococci and rickettsia. We report a case of streptococcal toxic shock syndrome in a 63-year-old female. She presented with irregular-shaped, massive ecchymoses and hemorrhagic bullae with progressive skin necrosis on her left thigh. Streptococcus pyogenes was found from blood culture and bulla, and multiple organ dysfunction occurred.

Streptococcal Toxic Shock Syndrome Occurred during Postoperative Radiotherapy in a Cancer Patient with Preexisting Lymphedema and Chronic Illness: Case Report / 대한방사선종양학회지

A case is reported of a man with malignant fibrous histiocytoma (MFH) in right thigh who developed streptococcal toxic shock syndrome (STSS) during postoperative radiotherapy. Before radiotherapy, a patient complained wax and wane lymphedema following wide excision of tumor mass which was confirmed as MFH. He took some nonsteroidal antiinflammatory drug (NSAID) for about one month. He suffered preexisting hepatitis C virus (HCV) infection, diabetes and well-controlled hypertension. The patient received conventional radiotherapy to right thigh with a total dose of 32.4 Gy at 1.8 Gy per day. At last radiotherapy fraction, cutaneous erythematous inflammation was suddenly developed at his affected thigh. At that time, he also complained of oliguria, fever and chills. The patient was consulted to internal medicine for adequate evaluation and management. The patient was diagnosed as suggested septic shock and admitted without delay. At admission, he showed hypotension, oliguria, constipation, abnormal renal and liver function. As a result of blood culture, Streptococcus pyogenes was detected. The patient was diagnosed to STSS. He was treated with adequate intravenous antibiotics and fluid support. STSS is one of oncologic emergencies and requires immediate medical intervention to prevent loss of life. In this patient, underlying HCV infection, postoperative lymphedema, prolonged NSAID medication, and radiotherapy may have been multiple precipitating factors of STSS.

Group A Streptococcal Infection and Its Present Condition in Korea / 감염

With introduction of penicillin and improvement of socioeconomic status, severe group A streptococcal (GAS) infections and their sequelae declined dramatically since 1970s. However, there have been worldwide reports on the increase in invasive GAS infections and the resurgence of rheumatic fever since mid-1980s. Necrotizing fasciitis and streptococcal toxic shock syndrome produce marked hypotension and fatal outcome with multiorgan failure. Mortality rate is over 30% in spite of intensive antibiotic treatment and surgical debridement of necrotic tissue. Scarlet fever is not uncommon, but toxic or septic scarlet fever is rare. In Korea poststreptococcal glomerulonephritis (PSGN) is increasing in Chinju city since 1994, while M12, a nephritogenic strain, was more common in Chinju (26.3%) and Seoul (48.8%). Because GAS is very common, highly contagious and cause fatal infections, bacteriological and epidemiologic studies on GAS infections should be continued. With resurgence of rheumatic fever in developed countries, the increasing incidence of PSGN in Chinju area may indicate the need of national surveillance program.

Streptococcal Toxic Shock Syndrome Associated with Intrauterine Fetal Death: A Case Report / 대한임상미생물학회지

The group A streptococcus is capable of producing exotoxins that have been linked to a toxic shock-like syndrome. Streptococcal toxic shock syndrome is a rapidly progressive associated with injury to multiple organ systems and a 30-60% mortality rate. These cases are very rare in Korea. We present a case of 32-year-old prenant woman who developed streptococcal toxic shock syndrome following intrauterine fetal death. She manifestated hypotension, shock, increased level of creatinine, disseminated intravascular coagulopathy, liver impairment, renal failure, pulmonary edema and adult respiratory distress syndrome. Blood cultures yielded Streptococcus pyogenes. After 17 hours on admission, she died in spite of massive transfusion, antibiotics therapy and ventilatory support. Clinicians should be alert to the importance of early diagnosis and treatment of this lethal infection.