Group A Streptococcal Toxic Shock Syndrome Developing inthe Third Trimester of Pregnancy

Abstract

Background: Group A streptococcal (GAS) toxic shock syndrome (TSS) is an uncommon, but life-threatening infection during pregnancy and should be considered in rapid onset of shock. Most cases described in the literature have occurred in the puerperium. We report a case of GAS TSS occurring during the third trimester of pregnancy in a previously healthy woman. Case: A 31-year-old female, who was 34 weeks pregnant, presented with fevers and a prodromal 'flu-like' illness. She rapidly developed shock and multiorgan failure. Blood cultures revealed GAS bacteremia and the patient met criteria for streptococcal TSS. Despite her eventual recovery, her infant died on postpartum day 15 as a consequence of the mother's TSS. Conclusions: This case is unusual in that there were no identifiable initiating events or source of the streptococcal infection, and the TSS developed during pregnancy rather than after delivery. Early recognition of GAS infections is important given the rapid onset and high morbidity and mortality associated with these infections. This is the first reported case utilizing intravenous immunoglobulin for GAS TSS in the puerperium.

Group A streptococcal toxic shock syndrome associated with pelvic peritonitis following diagnostic hysteroscopy in a healthy woman: a case report and review

“…These superantigens cause an aberrant proliferation of specific T cell subsets and directly activate thousands of times more T cells (up to 25% of total T cell population) than conventional antigens, to produce an accelerated cascade of cytokines such as interleukins and tumour necrosis factor with rapid clinical sequelae. It is at this stage that antibiotics alone may not be able to control the GAS infection [1,2,8].…”

“…Clindamycin has been recommended in addition to penicillin for all patients. Evidences from in vitro observations and animal studies indicate that clindamycin may be more effective than penicillin at inhibiting these organisms when they are present in high inocula and not dividing rapidly [1,2]. Harry Eagle first showed that streptococci present at high inoculum (>107 cfu/ml) are very slowly killed by penicillin.…”

“…It has been reported that over the last two decades there has been an increase in the incidence of invasive GAS disease. This trend may be related to the increasing prevalence of strains with specific M-proteins (M-1 and M-3) [1].…”

“…Group A streptococcal (GAS) toxic shock syndrome (TSS) associated with pelvic peritonitis following minor uterine manipulative procedures is however very rare and most reported cases have been in relation to pregnancy and puerperium [1][2][3][4]. Nyirjesy et al reported a case with streptococcal TSS following laparoscopic tubal ligation 5 weeks postpartum [5].…”

“…Invasive GAS infection is associated with toxic shock syndrome in 8-14% cases, resulting in shock and multi-organ failure soon after onset of symptoms, and is associated with a mortality of 33% despite antibiotics and supportive therapy [1,7]. It has been reported that over the last two decades there has been an increase in the incidence of invasive GAS disease.…”