Streptococcal Toxic Shock Syndrome

STSS is an uncommon clinical syndrome that involves multiple organ systems with fever, hypotension, and skin findings.12 The causative agent of this clinical disorder is Streptococcus pyogenes (group A Streptococcus). Streptococcal species produce extracellular proteins called streptococcal pyrogenic exotoxins (SPEs). Invasive soft tissue streptococcal infection, such as cellulitis, myositis, or fasciitis, is a common factor in the etiology of STSS.

The clinical presentation of STSS includes fever, hypotension, skin edema, and erythema, or bullae [ Fig, 2.4.1-4 (Plate...30)]. Subsequent desquamation occurs less commonly than during staphylococcal TSS. The same major and minor criteria used for the diagnosis of staphylococcal TSS can be helpful in identifying patients with STSS. According to a consensus document13 clinical features must include isolation of group A streptococci ( S. pyogenes) and hypoperfusion, as well as evidence of multisystem dysfunction. Because up to 75 percent of cases of STSS have associated soft-tissue infection, a thorough skin examination for the site of infection is warranted. Palpate muscle groups for tenderness, indicating possible myositis or fasciitis, and evaluate for secondary compartment syndrome. Treatment is oxygenation and fluid resuscitation. Because soft-tissue infection plays a large role in STSS, aggressive management of infection is essential. The site of infection should be identified, incised, and drained, and nonviable tissue debrided. Parenteral nafcillin, or oxacillin, or vancomycin, and a first-generation cephalosporin are often given as initial therapy.

FIG. 241-4 (PlateJO). Large bullous lesions on the lower extremity in a patient with streptococcal toxic shock.

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