American Journal of Emergency Medicine 31 (2013) 1293.e1-1293.e3

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Case Report

Trivial trauma, lethal outcome: streptococcal toxic Shock syndrome presenting to the ED?

Abstract

Group A Streptococcus, also known as Streptococcus pyogenes, is a common gram-positive bacterium that causes a broad spectrum of human infections ranging from uncomplicated pharyngitis and impe- tigo to life-threatening necrotizing fasciitis, bacteremia, and streptococ- cal toxic shock syndrome. Although it is rarely encountered in emergency departments, streptococcal toxic shock syndrome usually leads to a Catastrophic outcome. Here we present 2 young patients who experienced trivial traumas before admission, which, nevertheless, finally resulted in lethal streptococcal toxic shock syndrome.

Case 1. A 9-year-old boy presenting to the emergency department (ED) with a 1-day history of fever. Previously, he had been healthy. His parents reported that he had right ankle contusion 4 days before admission. On arrival, his vital signs were as follows: blood pressure, 131/91 mm Hg; pulse rate, 152 beats/min; respiratory rate, 26 breaths/min; and body temperature, 36?C. Physical examination revealed bluish discoloration on his right ankle (Fig. 1A). His chest x-ray was unremarkable. Laboratory tests revealed a leukocyte count of 8670/mm³, with 18% of bands; hemoglobin, 13.9 g/dL; and platelets, 41 000/mm³. Vancomycin and ceftazidime were prescribed. Rapid deterioration of his vital signs was noted, and cardiopulmonary collapse occurred soon. The boy died 2 hours later despite aggressive resuscitation. His blood cultures finally yielded group A Streptococcus (Streptococcus pyogenes), which was susceptible to penicillin, clin- damycin, and erythromycin.

Case 2. A healthy 10-year-old boy was referred to our ED with the complaint of cyanosis during the intravenous fluid infusion at a local clinic. He was brought to the clinic because of cough, rhinorrhea, and fever. His parents reported that he experienced right ankle contusion 4 days before. On arrival, respiratory distress was observed, and his blood pressure was undetectable. Physical examination revealed inspiratory crackles on his both lung fields. Bruises on his right ankle were disclosed (Fig. 1B). Chest x-ray showed interstitial and confluent opacity in both lungs (Fig. 2). Laboratory tests revealed a leukocyte count of 9030/mm³, with 79% of neutrophils, 1% of myelocytes, and 3% of bands; hemoglobin, 13 g/dL; and platelets, 48 000/mm³. Respira- tory failure with severe desaturation occurred soon at ED. Extracor- poreal membrane oxygenation was used to provide cardiac and respiratory support. Vancomycin and ceftazidime were given. Unfortunately, he died of multiple-organ failure 8 hours after admission. The polymerase chain reaction assay of throat swab for influenza virus was negative. His blood culture finally yielded group A

? This work was supported by the E-Da Hospital (Grant No. EDAHP102011).

Streptococcus, which was susceptible to penicillin, clindamycin, and erythromycin.

Molecular traits of microorganisms are strongly related to streptococcal toxic shock syndrome (STSS). To investigate the molecular characteristics, we performed emm typing of these 2 group A Streptococci according to the protocol of the Centers for Disease Control and Prevention [1]. Both isolates were emm1, which has been found to be associated with shock and Severe outcomes in Europe and the United States [2,3]. Superantigens produced by group A Streptococcus can bypass traditional antigen processing and lead to a sudden cytokine storm resulting in toxic shock [4,5]. We examined superantigens of speA, speB, speC, speF, speG, speH, speJ, ssa, and smeZ using polymerase chain reactions modified from the previous protocol [6]. Superantigens analysis detected speA, speB, speF, and speG in the isolate from case 1 and speA, speB, speG, speJ in the isolate from case 2. speA has shown to be commonly found in patients with STSS caused by emm1 group A Streptococcus [2]. The role of superantigens in STSS needs further elucidation. All emm1 isolates collected in our hospital during the past 2 years were sent for pulsed-field gel electrophoresis to investigate the epidemiologic relation between these isolates [7], and the analysis revealed that these 2 isolates belonged to distinct clusters (Fig. 3).

Toxic shock syndrome caused by group A Streptococcus is a rare but severe disease. Recently, epidemiologic studies have reported an increased incidence of STSS in Europe and the United States [8,9]. The reported mortality rate varied from 4% to 44% [8,9]. Although the portal of group A Streptococcus entry cannot be confirmed in a substantial number of patients with STSS, most patients experience a minor local trauma that often has no breakage in skin [10]. Other risk factors that could be associated with STSS include previous surgery, viral infections (varicella and influenza), and nonsteroid anti- inflammatory drugs use [10]. Besides fever and shock, the clinical manifestations of STSS include nausea, vomiting, diarrhea, abdominal pain, and flu-like symptoms [10,11]. The principles of treatments of STSS include supportive care and adequate administration of antimicrobial agents (Penicillin G combined with clindamycin) [4]. Intravenous immunoglobulin is controversial for this critical disease [4].

In this report, both patients only had a minor trauma on their ankles before admission, but they finally died of severe group A Streptococcal infections. Both presented with rapidly progressive deterioration of clinical condition in the ED. One presented with flu- like symptoms. Neither patient received appropriate antimicrobial agents because STSS was not suspected. Although it rarely encoun- tered in the ED, STSS frequently leads to a lethal outcome. Because STSS usually displays diverse manifestations, ED physicians should take this catastrophic disease into consideration in patients who

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Fig. 1. Bruises on right ankles were observed in case 1 (A) and case 2 (B).

present with shock and have a history of trauma, even if trivial, before admission.

Jiun-Nong Lin MD

Graduate Institute of Medicine

College of Medicine Kaohsiung Medical University

Kaohsiung, Taiwan Department of Critical Care Medicine E-Da Hospital, I-Shou University

Kaohsiung, Taiwan

Lin-Li Chang PhD

Department of Microbiology Faculty of Medicine, College of Medicine Kaohsiung Medical University

Kaohsiung, Taiwan

Fig. 2. Chest x-ray of case 2 showed interstitial and confluent opacity in the both lungs.

Chung-Hsu Lai MD Hsi-Hsun Lin MD

Division of Infectious Diseases Department of Internal Medicine E-Da Hospital, I-Shou University

Kaohsiung, Taiwan

Yen-Hsu Chen PhD, MD

Graduate Institute of Medicine, College of Medicine

Kaohsiung Medical University

Kaohsiung, Taiwan Division of Infectious Diseases Department of Internal Medicine Kaohsiung Medical university hospital

Kaohsiung, Taiwan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.04.011

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    Fig. 3. Dendrogram of pulsed-field gel electrophoresis from 13 group A Streptococcus isolates digested by the SmaI restriction enzyme shows that the isolates from cases 1 and 2 belong to distinct clusters.