Streptococcal toxic shock syndrome (STSS) is a life-threatening disease caused by infection of
Management of streptococcal toxic shock syndrome (STSS), a rare and life-threatening disease, requires immediate surgical intervention in addition to administration of appropriate antibiotics and intravenous immunoglobulin (IVIG) in an intensive care setting to achieve a favorable outcome. Here, we report our experience with a rare and extremely severe case of STSS combined with both diffuse peritonitis and necrotizing fasciitis (NF).
A 65-year-old woman with untreated diabetes visited our emergency department for a one-day history of lower abdominal pain. Abdominal findings showed diffuse peritonitis. Computed tomography showed edema of the small intestine and bladder wall. Perforation of the appendix, alimental tract, or urinary tract was suspected; thus, emergency surgery was performed. Although there were purulent ascites, remarkable redness, and edema of both the small intestine and bladder wall throughout the lower abdominal cavity, there was no perforation of the gastrointestinal or urinary tract (Figure
Case 1. (a, b) Admission day. Emergent laparotomy findings. The bladder wall and peritoneum showed remarkable redness and edematous changes (a). Left pretibial skin showed erythema and a few small scabs (b). (c) Four days after admission. The deeper section where scabs of the pretibial area were removed showed severe necrotic findings. (d) Two weeks after admission. After several rounds of debridement for NF at the pretibial area.
STSS is a rapidly progressive and fatal disease caused by beta-hemolytic streptococcus infection with GAS as the most common pathogen [
Our case presented with the unusual features of both diffuse peritonitis and NF. The maximum SOFA score was 10 points at two hospital days. It represents an extremely life-threatening condition due to the high bacterial load and a subsequent extreme immune reaction. Advanced intensive supportive care and aggressive surgical intervention are indispensable for such cases. However, it is necessary to distinguish STSS with diffuse peritonitis from diffuse peritonitis caused by transvaginal infections in premenopausal females.
In the present case, there was no purulent subglossal inflammation or infection from the vaginal insertion of sanitary products. Further, because the infectious findings of the lower extremity gradually became more severe each day, the final diagnosis was secondary peritonitis accompanied by a soft tissue infection.
Malota et al. and Iitaka et al. summarized the clinical presentation of patients with GAS peritonitis [
Of such cases of GAS peritonitis, STSS with both diffuse peritonitis and NF is infrequent. According to a review report by Malota et al., the frequency of this clinical presentation is 6% (2/35) [
Reports on STSS with peritonitis and NF.
Author | Year | Age/sex | Details of laparotomy | NF | IVIG | Mechanical support | Prognosis after discharge |
---|---|---|---|---|---|---|---|
Monneuse et al. [ |
2010 | N/A | At least washing and drainage | Axillary, chest, leg | N/A | N/A | Alive, at least 3 months |
Monneuse et al. [ |
2010 | N/A | At least washing and drainage | Nose, finger | N/A | N/A | Alive, at least 3 months |
Present case | 2018 | 65F | Washing and drainage | Leg | + | CHDF, ventilation | Alive, 7 years |
Abbreviations: CHDF: continuous hemodiafiltration; IVIG: intravenous immunoglobulin; N/A: not applicable; NF: necrotizing fasciitis.
The critical points of a therapeutic strategy for STSS are as follows:
Intensive care and supportive management Appropriate administration of antibiotics and IVIG Aggressive surgical intervention for infectious sites
The pathophysiology of STSS is similar to that of septic shock. Therefore, systemic management is based on the treatment regimen for septic shock. Specifically, immediate and intensive treatment with colloidal fluid resuscitation, inotropic agents, adequate alimental support, and mechanical ventilation is indispensable for a favorable outcome, if needed [
As a first-line antimicrobial therapy for NF with streptococcal infection, high-dose penicillin G and clindamycin are recommended [
IVIG administration is a valuable adjunctive therapy for STSS and probably offers a survival benefit. There have been several reports of highly successful cases of IVIG administration for the treatment of STSS. IVIG contains broad-spectrum antibodies against streptococcal superantigens and M proteins. Furthermore, anti-inflammatory effects have also been recognized, which decrease the production of proinflammatory cytokines (e.g., tumor necrosis factor alpha, interluekin-1 alpha, and interluekin-6), downregulate the expression levels of chemokines and chemokine receptors, and neutralize superantigens [
Appropriate surgical intervention, including aggressive debridement and drainage of necrotizing soft tissue infections or other infection sites, is an essential therapeutic strategy to achieve a successful outcome. Several reports have shown a 7–9-fold increased risk of death with inadequate or delayed initial debridement or surgical intervention. To suppress disease progression, surgical intervention must be performed as early as possible and should be repeated subsequently depending on the clinical course of the soft tissue or other infection [
STSS is an extremely aggressive and life-threatening disease. When diffuse peritonitis with unknown origin is identified during the initial surgery, STSS must be considered. Further, both evaluation of soft tissue infection and preparation for deterioration of physical status are significant in such cases. If a diagnosis of STSS is likely, immediate and aggressive therapeutic interventions, including appropriate antibiotic administration, IVIG, and intensive care, are indispensable to achieve a successful treatment outcome. In addition, CHDF is essential as mechanical support for renal dysfunction and cytokine regulation. Further, repeated surgical intervention, depending on the status of the infection, is also necessary.
The authors have no conflict of interest to declare regarding the publication of this article.
The authors thank Christopher Chen for the editorial and educational assistance.