Toxic Shock Syndrome due to Group A Streptococcus infection in an Intensive Care Unit: Case Report
DOI:
https://doi.org/10.65332/rpdi.v20.126Palavras-chave:
Toxic shock syndrome, Intensive Care Units, Streptococcus pyogenesResumo
Introduction: Toxic shock syndrome (TSS) is a rare but potentially fatal condition caused by exotoxins produced by Streptococcus pyogenes or Staphylococcus aureus. Streptococcal toxic shock syndrome (STSS) is characterized by rapid clinical deterioration and requires prompt recognition, aggressive supportive care, and multidisciplinary management.
Case Presentation: We report the case of a 63-year-old previously healthy Angolan man visiting Portugal who presented to the Emergency Department with a seven-day history of painful swelling of the left thigh and inguinal region, unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs). He rapidly developed septic shock with multiorgan failure, requiring invasive mechanical ventilation, vasopressor support, and renal replacement therapy, and was admitted to the Intensive Care Unit. Blood cultures were negative, but Streptococcus pyogenes was isolated from a skin biopsy culture, supporting the diagnosis of STSS. The patient improved with targeted antibiotic therapy and was extubated after five days. Subsequently, he developed severe upper gastrointestinal bleeding from a bleeding antral ulcer, complicated by refusal of blood transfusion, and was managed conservatively.
Conclusion: STSS is a fulminant and life-threatening condition. Early diagnosis, aggressive organ support, and multidisciplinary care are essential. NSAIDs use may exacerbate disease severity and contribute to gastrointestinal complications. Refusal of blood transfusion poses major clinical and ethical challenges in the management of critically ill patients.
Referências
1. Atchade E, De Tymowski C, Grall N, Tanaka S, Montravers P. Toxic shock syndrome: a literature review. Antibiotics (Basel). 2024;13(1):96. https://doi.org/10.3390/antibiotics13010096 DOI: https://doi.org/10.3390/antibiotics13010096
2. Gottlieb M, Long B, Koyfman A. The evaluation and management of toxic shock syndrome in the emergency department: a review of the literature. J Emerg Med. 2018;54(6):807--814. https://doi.org/10.1016/j.jemermed.2017.12.048 DOI: https://doi.org/10.1016/j.jemermed.2017.12.048
3. Lamagni TL, Efstratiou A, Vuopio-Varkila J, Jasir A, Schalén C. The epidemiology of severe Streptococcus pyogenes-associated disease in Europe. Euro Surveill. 2005;10(9):563. https://doi.org/10.2807/esm.10.09.00563-en DOI: https://doi.org/10.2807/esm.10.09.00563-en
4. Tavares T, Domingos J, Zaruba V, Nobre C, Sousa M. Toxic shock syndrome due to Streptococcus pyogenes: a case series. Cureus. 2025;17(8):e91342. https://doi.org/10.7759/cureus.91342 DOI: https://doi.org/10.7759/cureus.91342
5. O’Loughlin RE, Roberson A, Cieslak PR, Lynfield R, Gershman K, Craig A, et al. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000--2004. Clin Infect Dis. 2007;45(7):853--862. https://doi.org/10.1086/521264 DOI: https://doi.org/10.1086/521264
6. Stevens DL, Bryant AE. Severe group A streptococcal infections. In: Streptococcus pyogenes: basic biology to clinical manifestations [Internet]. Oklahoma City: University of Oklahoma Health Sciences Center; 2016. https://www.ncbi.nlm.nih.gov/books/NBK333425/
7. Factor SH, Levine OS, Schwartz B, Harrison LH, Farley MM, McGeer A, Schuchat A. Invasive group A streptococcal disease: risk factors for adults. Emerg Infect Dis. 2003;9(8):970--977. https://doi.org/10.3201/eid0908.020745 DOI: https://doi.org/10.3201/eid0908.020745
8. Centers for Disease Control and Prevention. Streptococcal toxic shock syndrome: for clinicians [Internet]. Atlanta: CDC; 1995 [cited 2025 Nov 16]. https://ndc.services.cdc.gov/case-definitions/streptococcal-toxic-shock-syndrome-1995/
9. Schmitz M, Roux X, Huttner B, Pugin J. Streptococcal toxic shock syndrome in the intensive care unit. Ann Intensive Care. 2018;8:88. https://doi.org/10.1186/s13613-018-0438-y DOI: https://doi.org/10.1186/s13613-018-0438-y
10. Duvanel T, Auckenthaler R, Rohner P, Harms M, Saurat JH. Quantitative cultures of biopsy specimens from cutaneous cellulitis. Arch Intern Med. 1989;149(1):293--296. PubMed PMID: 2644902. DOI: https://doi.org/10.1001/archinte.1989.00390020039008
11. Pan B, Sun P, Pei R, Lin F, Cao H. Efficacy of intravenous immunoglobulin therapy for patients with sepsis: a systematic review and meta-analysis. J Transl Med. 2023;21(1):765. https://doi.org/10.1186/s12967-023-04592-8 DOI: https://doi.org/10.1186/s12967-023-04592-8
12. Linnér A, Darenberg J, Sjölin J, Henriques-Normark B, Norrby-Teglund A. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study. Clin Infect Dis. 2014;59(6):851--857. https://doi.org/10.1093/cid/ciu449 DOI: https://doi.org/10.1093/cid/ciu449
13. Al Akhrass F, Abdallah L, Hrizat A, Hanif S. Toxic shock and shock-like syndrome: the constant threat. Clin Surg. 2019;4:2526. Available from: http://clinicsinsurgery.com/open-access/toxic-shock-and-shock-like-syndrome-the-constant-threat-5414.pdf
14. Babiker A, Li X, Lai YL, Strich JR, Warner S, Sarzynski S, et al. Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive beta-hemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort study. Lancet Infect Dis. 2020;20(5):614--622. https://doi.org/10.1016/S1473-3099(19)30524-3 DOI: https://doi.org/10.1016/S1473-3099(20)30523-5
Downloads
Publicado
Edição
Secção
Licença
Direitos de Autor (c) 2026 Ana Catarina Rodrigues Goncalves, Teresa Valido, João Patrício, Hugo Inácio, André Gordinho, Ângela Simas, Carlos Pereira (Autor)
Este trabalho encontra-se publicado com a Licença Internacional Creative Commons Atribuição 4.0.
