Moffitt AM Report 12/20/16: Streptococcal Toxic Shock Syndrome

Thank you Bridget, Lily, and Kresh for presenting a case of a young man with hypertension who presented with acute onset, bilateral testicular swelling, and was ultimately found to have streptococcal toxic shock syndrome and stress cardiomyopathy!

TOP PEARLS

  • Consider toxic shock syndrome (TSS) when patients present with significant skin/soft tissue pain out of proportion to examination.
  • For Streptococcal toxic shock syndrome, strep pyogenes (Group A strep) is the most frequent organism.
  • Renal failure occurs in most all patients with TSS, resulting from significant shock, myoglobinuria, and hemoglobinuria.


Streptococcal Toxic Shock Syndrome (TSS)

  • most frequently occurs in the setting infection due to group A Streptococcus (GAS; Streptococcus pyogene)
  • Pathophysiology: Superantigens!
    • GAS is an aerobic gram-positive coccus that releases exotosins that act as a superantigen, that activates the immune system by bypassing the usual antigen-mediated immune response sequence!
    • Thank you Amy Berger (Molecular Medicine fellow) for providing us with this diagram below.
      toxic-shock
  • How to diagnose?
    • Consider the clinical history: history of recent trauma, severe, pain, fever
    • Clinical guideline for Group A Strep TSS: – Isolation of GAS from normally sterile site (blood, CSF, pleural fluid, peritoneal fluid, tissue biopsy, surgical wound) – Hypotension PLUS 2 or more of the following: – Renal dysfunction – Coagulopathy – Liver dysfunction – ARDS – Erythematous macular rash – Soft tissue necrosis
  • Clinical Manifestations
    • Typically presents with pain that precedes physical findings of infection. Clinical signs of SSTI consist of localized swelling and erythema followed by ecchymoses, with progression to necrotizing fasciitis or myositis
    • Complications include bacteremia, renal failure, ARDS, DIC, Waterhouse-Friderichsen Syndrome
    • Renal failure occurs in nearly all patients within 48-72 hrs. Hypotension, myoglobinuria, and hemoglobinuria (due to toxin-induced hemolysis) can contribute.
  • Treatment of TSS
    • Resuscitation and source control (surgical debridement, vaginal examination in all women)
    • Antibiotics to reduce organism load
    • Clindamycin: protein synthesis inhibitor to decrease toxin production
    • IVIG: Toxin neutralization, non-specific anti-inflammatory effects

 

Stress Cardiomyopathy

 

Evernote Link: https://www.evernote.com/shard/s338/sh/6935ab72-22e7-41c9-9cc8-4793cd45261d/f35a0e228151994c2ef88ef667ecaedf

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