Group a streptococcal toxic shock syndrome with severe necrotizing fasciitis following hysterectomy — a case report

Abstract

In the last 10 years an increasing number of cases of group A streptococcal toxic shock syndrome have appeared in various clinical settings. The manifestation of this syndrome includes rapidly progressive multiorgan failure and soft-tissue necrosis. This report presents a case of streptococcal toxic shock syndrome caused by Streptococcus pyogenes with severe necrotizing fasciitis of the abdominal wall following hysterectomy. Aggressive surgical intervention with debridement of all necrotic tissue necessitated resection of the complete abdominal wall (skin, subcutaneous tissue, muscle and peritoneum). The abdominal wall defect was covered with free myocutaneous flaps and split-skin grafts. Optimal treatment, including adequate antibiotic therapy and radical surgical intervention, is an indispensable prerequisite of successful outcome.

Creatine Kinase as an Indicator for Hysterectomy in Postpartum Endomyometritis due to Group A Streptococci: A Hypothesis Illustrated by a Case Report

“…Since the mid-1980s, GAS has made a revival and has been associated mainly with severe cases of puerperal sepsis [3,4,5]. This trend may be related to the increasing prevalence of strains with specific M proteins, namely M1 and M3 [2,3,4,5]. …”

“…The severity of GAS infections is due to exotoxin A, which is produced by the M1 and M3 serotypes [2,5]. Group A streptococci produce a number of virulence factors.…”

“…CRP became negative and there were no more episodes of fever. The patient was discharged in good physical condition 17 days postpartum, and antibiotics were stopped 21 days postoperatively [2]. The baby was extubated on day 8 of life and inotropy was stopped on day 4.…”

“…Six hours after delivery, the baby was admitted to the neonatal ward because of respiratory distress. Due to combined metabolic and respiratory acidosis, continuous positive airway pressure (CPAP) was started [2]. Twelve hours after birth the baby was transferred to our Neonatal Intensive Care unit where he was intubated.…”

“…One third of deep infections are complicated by toxic shock syndrome [1]. Streptococcal toxic shock syndrome (STSS) is defined as isolation of GAS from a normally sterile site and hypotension (systolic blood pressure less than 90 mm Hg) accompanied by two or more of the following: renal impairment defined as creatinine >2 mg/dl; coagulopathy, liver involvement defined as >2 times the upper limit of transaminases or bilirubin, acute respiratory distress syndrome (ARDS), erythematous macular rash, or soft tissue necrosis, such as necrotizing fasciitis or myositis [1,2,3]. Treatment of STSS includes hemodynamic support, antibiotherapy, and sometimes surgery.…”