Treatment of postoperative purulent pericarditis and streptococcal toxic shock syndrome by intensive blood purification.

S toxic shock syndrome (STSS), a severe infectious disease caused by group A hemolytic streptococcus (Streptococcus pyogenes [S. pyogenes]) in patients with purulent pericarditis has hardly ever been reported in the literature. We experienced an extremely rare case of STSS caused by a purulent pericarditis following multiple stab wounds. The patient was successfully treated with intensive blood purification techniques and penicillin. The case we present suggests that intensive blood purification might be useful in alleviating development of S. pyogenes infection by protecting important organs, and removing endotoxins before the outcome of bacterial cultivates. A 27-year-old male was admitted to the emergency department with stab wounds on his left shoulder, chest, upper and middle abdomen, and thigh. An urgent exploratory thoracotomy with cardiorrhaphy, pulmonary lobe repair, and exploratory laparotomy with liver and stomach rupture repair were performed. After 4 days, laboratory studies revealed a white blood cell (WBC) count of 13×109/L, liver and renal function tests were normal. After 10 days, he became dysphoric with profuse sweating, dyspnea, and chest pain. Physical examination revealed a temperature of 36.4°C, heart rate of 149 beats/min, respiratory rate of 35/min, blood pressure (BP) of 84/60 mm Hg, paleness, clammy palms and soles, and peripheral cyanosis. A decreased breath sound of the left lung, and low intensity heart sounds were found. Oxygen saturation measured by pulse oximetry was 86%. Laboratory tests showed a WBC of 38.94×109/L, 92.7% neutrophil percentage, and high levels of aspartate aminotransferase (AST [1395 IU/L]), and alanine transaminase (ALT [1093 IU/L]). The chest CT showed a large amount of pericardial effusion and bilateral pleural effusion (Figures 1A & 1B). His urine volume was 460 ml/day. He was initially thought to be in septic shock introduced by purulent pericarditis. He therefore received intravenous fluid resuscitation, imipenem and ornidazole, and support care including nutrition, breathing, and so forth. A follow-up examination showed a substantial elevation of ALT, AST, serum creatinine (sCr) and cystatin C (CysC), and we considered the need for circulation support and toxin removal. Continuous veno-venous hemodiafiltration (CVVH) was performed on the patient using PRISMA platform (AN69-ST membranes, Gambro, Hechingen, Germany). The ultrafiltration rate dose was targeted to 50 mL/kg/hour. Meanwhile, a left exploratory thoracotomy was carried out. A large amount of yellowish-white pus overflowed from the pericardial cavity, (a total of approximately 10 ml) and part of the pus was sent to the laboratory for bacterial cultivate and drug susceptibility tests. After the operation, plasma exchange (PE) was performed. The filter was a membrane filter (Plasmaflo OP-05W, Kasei, Japan), and the exchange volume was fresh-frozen plasma (approximately 3,000 ml) at an exchange rate of 15 ml/min. The first PE was carried out in the morning of the eleventh day, and the second at night. He became calm, his BP was 100/62 mm Hg, and his heart rate was 101 beats/min after the first PE. On day 13, the WBC count, AST, and ALT decreased, and the urine volume increased to 1160 ml/day. The changes of indicators are shown in Figure 2. The output of bacterial cultivates was pyogenic streptococcus. The organism was susceptible to ampicillin, cefotaxime, and ceftriaxone. Clinical Note