Community-acquired streptococcal toxic shock syndrome.

Group A streptococcus (Streptococcus pyogenes) may cause a variety of illnesses ranging from very common, usually clinically mild conditions such as pharyngitis and impetigo to less common severe infections including septicaemia [1]. With the resurgence of serious forms of group A streptococcal infection noted in many parts of the world, cases of streptococcal toxic shock syndrome (STSS) have been reported. The generally accepted case definition for STSS specifies isolation of the organism, substantial hypotension and two or more of the following features: renal or hepatic failure, coagulopathy, adult respiratory distress syndrome, generalized rash and soft tissue necrosis [1]. Despite optimal treatment the mortality of STSS ranges from 30 to 70% [2-6]. Recently, published data from 11 European countries gave an incidence of STSS of 13% in streptococcal infection from any source [6]. In this letter, we report a case of STSS. An 82-year-old woman was admitted to our hospital due to a 12-hour history of fever and altered mental status. She was allergic to penicillin and she had diabetes mellitus. On admission her body temperature was 39.1oC. Her pulse rate, blood pressure and respiratory rate were normal. She was confused. On physical examination, she had a small ulcer in her left foot. Other physical examination findings were normal. The white cell count was 17,800/mm with a left shift and C-reactive protein was 13.8 mg/dl. Glucose was 143 mg/dl and liver dysfunction was revealed as a total bilirubin 2.2 mg/dl, aspartate aminotransferase 126 IU/L and alanine aminotransferase 50 IU/L. The prothrombin time was 52% and the PTT was twice the normal level. On the first hospital day, antibiotic treatment with ciprofloxacin and clindamycin was started. On the third hospital day, she developed refractory hypotension and respiratory failure. Despite maximal supportive therapy, she died. Streptococcus pyogenes was isolated from blood culture. The organism was typed as M1, T1 which was sensitive to penicillin, cephalosporin and clindamycin and was found to be producing streptococcal pyrogenic exotoxin (SPE) B and C in vitro. In most cases of STSS the patients are previously healthy, and the site of infection is usually skin or soft tissue, although some are puerperal or, rarely, pharyngeal. A number of predisposing factors for nonnecrotizing cellulitis broadly includes conditions involving alterations in integrity of skin; alterations in vascularity of skin and alteration of host defences (eg, diabetes mellitus) [7]. Our patient had an ulcer in her left foot and she was also diabetic. Most (60%) patients with STSS have a positive blood culture [8]. Presence or absence of bacteraemia does not affect mortality. The diagnosis of STSS is confirmed when Streptococcus pyogenes are cultured from normally sterile body fluids in a patient with shock and multi-organ failure [9]. Lettere all’Editore