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Toxic shock syndrome

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Acute Life-Threatening Group A Streptococcal Infections

Dennis L. Stevens, Ph.D., M.D

Streptococcal TSS

Recently, severe invasive GAS infections associated with shock and organ failure have been reported with increasing frequency, predominantly from North America and Europe (8-18). These infections have been termed streptococcal toxic-shock syndrome (TSS; Table 1) (19). Persons of all ages are affected; most do not have predisposing underlying diseases (11,20-25). This is in sharp contrast to previous reports of GAS bacteremia, in which patients were either under 10 or over 60 years of age, and most had underlying conditions such as cancer, renal failure, leukemia, or severe burns or were receiving corticosteroids or other immunosuppressing drugs (20-22). The complications of current GAS infections are severe; bacteremia associated with aggressive soft tissue infection, shock, adult respiratory distress syndrome and renal failure are common; 30% to 70% of patients die in spite of aggressive modern treatments (Table 2) (1,8,24-26).

Table 1. Case definition of streptococcal toxic-shock syndrome

(streptococcal TSS) and necrotizing fasciitis*


I. Streptococcal TSS

   A. Isolation of group A Streptococcus

      1. From a sterile site

      2. From a nonsterile body site

   B. Clinical signs of severity

      1. Hypotension

      2. Clinical and laboratory abnormalities (requires two or 

         more of the following):

         a)Renal impairment


         c)Liver abnormalities

         d)Acute respiratory distress syndrome

         e)Extensive tissue necrosis, i.e., necrotizing fasciitis

         f)Erythematous rash


  Definite Case = A1 + B(1+2)

  Probable Case = A2 + B(1+2)


II. Necrotizing fasciitis

    A. Definite case

      1. Necrosis of soft tissues with involvement of the fascia


      2.Serious systemic disease, including one or more of the



        b)Shock (systolic blood pressure <90 mm of Hg).

c)Disseminated intravascular coagulopathy

d)Failure of organ systems a.respiratory failure b.liver failure c.renal failure

3.Isolation of group A Streptococcus from a normally sterile

       body site

     B.Suspected case

      1.1+2 and serologic confirmation of group A streptococcal

      infection by a 4-fold rise against:

        a)streptolysin O

        b)DNase B

      2.1+2 and histologic confirmation:

      Gram-positive cocci in a necrotic soft tissue infection


*Streptococcal toxic-shock syndrome (streptococcal TSS) is

defined as any group A streptococcal infection associated with

the early onset of shock and organ failure.  Definitions

describing criteria for shock, organ failure, definite cases,

and probable cases are included below.

Source: reference 61.


Table 2. Complications of group A streptococcal soft-tissue




Complication                                  of Patients



Shock                                             95

Acute respiratory distress syndrome     55

Renal impairment                               80

 Irreversible                                     10

 Reversible                                       70

Bacteremia                                       60

Death                                             30

Source: reference 1.

Acquisition of Group A Streptococcus

The portal of entry of streptococci cannot be proven in at least half the cases (8) and can only be presumed in many others.

Patients with symptomatic pharyngitis rarely develop streptococcal TSS, though such cases have been reported,especially in the last year.

Procedures such as suctionlipectomy, hysterectomy, vaginal delivery, bunionectomy and bone pinning have provided a portal of entry in many cases (author's unpublished observations).

Most commonly, infection begins at a site of minor local trauma, which frequently does not result in a break in the skin (8).

Numerous cases have developed within 24 to 72 hours of minor nonpenetrating trauma, resulting in hematoma, deep bruise to the calf, or even muscle strain.

Virus infections, such as varicella and influenza, have provided a portal in other cases. In some cases the use of nonsteroidal antiinflammatory agents may have either masked

the early symptoms or predisposed the patient to more severe streptococcal infection and shock (1).

For the most part, these infections have occurred sporadically and have not been associated with clusters of cases or minor epidemics,

though outbreaks of severe GASinfections have occurred in closed environments such as nursing homes (27,28).

Toxic shock syndrome > 1 > 2 > 3 > 4

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