Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A.

There is concern that group A streptococci, which have caused less serious infections in developed countries in recent decades, may be acquiring greater virulence. We describe 20 patients from the Rocky Mountain region who had group A streptococcal infections from 1986 to 1988 that were remarkable for the severity of local tissue destruction and life-threatening systemic toxicity. Among the 20 patients (median age, 36), necrotizing fasciitis with or without myositis was the most common soft-tissue infection (55 percent). Nineteen patients (95 percent) had shock, 16 (80 percent) had renal impairment, and 11 (55 percent) had acute respiratory distress syndrome. The mortality rate was 30 percent. All patients but 1 had positive tissue cultures for Streptococcus pyogenes; 12 had positive blood cultures. Most of the patients had no underlying disease; 2 used intravenous drugs. Strains of group A beta-hemolytic streptococci isolated from 10 patients were not of a single M or T type; however, 8 of the 10 strains produced pyrogenic exotoxin A (scarlet fever toxin A, a classic erythrogenic toxin), which has rarely been observed in recent years. From our study of this cluster of severe streptococcal infections with a toxic shock-like syndrome, we conclude that in our region, more virulent group A streptococci have reappeared that produce the pyrogenic toxin A associated with scarlet fever.

Toxic shock syndrome from Staphylococcus aureus infection at insulin pump infusion sites. Report of two cases.

Two young diabetic females using insulin infusion pump therapy became ill with toxic shock syndrome secondary to Staphylococcus aureus infection at the insulin infusion pump site. Physicians need to be aware of this potential complication in diabetic patients using insulin infusion pump therapy so proper management can be initiated early. Infections at insulin infusion sites are common. Patients need to be instructed in the importance of preventing infections at the pump infusion site and proper management of any abscesses that should develop. Controlled studies evaluating proper management of insulin infusion pump sites to prevent infections are needed.

The nature of an infectious disease practice in a community hospital.

Populations of patients in community and university-affiliated teaching hospitals differ, and therefore, problems encountered by infectious disease specialists in these two types of hospitals also differ. However, most infectious disease specialists are trained only in university hospitals. In order to characterize the nature of an infectious disease practice in a community hospital, the authors report data for the patients seen during a period of three years (July 1978-June 1981). Most of the 1,238 cases were referred by other physicians. General practitioners referred 35% of the cases, whereas internists, orthopedists, and surgeons referred 20%, 16%, and 10% respectively. Skin and wound infections accounted for the largest percentage of referrals (16%). Fever accounted for 9%, abdominal problems for 6%, and respiratory infections for 6%. Other problems referred to the infectious disease service included infections of the central nervous system, urinary tract infections, osteomyelitis, and arthritis.

Toxic shock syndrome.

Eight cases of toxic shock syndrome, confirmed by Center for Disease Control criteria, involved women who were menstruating and were tampon users. Each patient had severe febrile illness with rash, associated hypotension, renal and liver function abnormalities, pharyngitis and vaginitis. An examination of the literature indicates that cases that were reported as adult Kawasaki disease may actually have been toxic shock syndrome.