A Case Study of Puerperal Group A Streptococcal Infection Complicated by Toxic Shock Syndrome

Abstract

Puerperal infection with group A streptococcus (GAS), Streptococcus pyogenes, is associated significant morbidity and mortality. When associated with toxic shock syndrome (TSS), mortality rates rise to approximately 50%. We present the case of a 32-year-old Para 2 reporting severe left distal lower extremity pain, fevers, and chills at 1 week following an uncomplicated vaginal delivery. The patient's clinical status rapidly decompensated to septic shock requiring transfer to the intensive care unit. She underwent anterior and lateral compartment fasciotomy of the left lower extremity for concerns of possible necrotizing soft tissue infection. Final blood cultures confirmed GAS infection with unclear primary source, though endometritis was favored. She required additional orthopaedic procedures including an arthroscopy with washout for contralateral septic arthritis and myositis before her discharge on hospital day 19. She obtained a near-full recovery complicated by poor wound healing and permanent left foot drop. While GAS remains a rare puerperal event, obstetricians should recall there is a 20-fold increased incidence among postpartum women. Progression to TSS is associated with very poor prognosis and hysterectomy is often necessary. Favorable outcomes in GAS with or without TTS hinge on astute clinical suspicion, aggressive fluid resuscitation, early antibiotic therapy, and source control.

A Review of Streptococcus pyogenes: Public Health Risk Factors, Prevention and Control

“…Other prevention and control measures include improving the quality of housing [ 15 , 20 ], improved hand hygiene practices [ 15 , 42 ] and the reduction of overcrowding [ 15 ]. Other proposed methods to reduce GAS transmission that are not currently used include vaccination [ 89 , 102 , 107 , 108 , 109 , 110 ] and screening for GAS during pregnancy [ 41 , 63 , 67 , 97 , 119 ].…”

“…The results of a study carried out by Rottenstreich et al [ 67 ] reported that pregnant women were 20 times more at risk of GAS infections than non-pregnant women. This has been attributed to changes in host immunity due to pregnancy or postpartum status [ 103 , 119 ]. Studies carried out on pregnant women also reveal that GAS infections can cause still births and neonatal deaths [ 65 ].…”

“…Reducing antibiotic resistance will further reduce the transmission of GAS infections through increased treatment success, as discussed earlier. Studies have also proposed screening for invasive GAS during pregnancy so as to prevent transmission to pregnant women who are a high-risk group for GAS infections [ 41 , 63 , 67 , 97 , 119 ].…”

Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review

“…Pregnancy is a highly immunomodulated state which increases the risk of invasive GAS infection by 20‐fold in comparison to the non‐pregnant population 11 . Most people develop invasive GAS from ascending infection of the genital tract and endometrium, which can quickly progress to septic shock and multiorgan failure within 48–96 hours as evidenced by multiple case reports in the literature 12 …”

“…11 Most people develop invasive GAS from ascending infection of the genital tract and endometrium, which can quickly progress to septic shock and multiorgan failure within 48-96 hours as evidenced by multiple case reports in the literature. 12 The objective of this study was to systematically review the pregnancy and puerperal outcomes and management strategies in cases of GAS infection in an effort to provide further guidance for prevention and treatment of a rare but lethal infection worldwide.…”