title: Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach.
abstract: Intravenous polyspecific immunoglobulin G (IVIG) has been reported to be efficacious as adjunctive therapy in patients with toxic shock syndrome caused by a group A streptococci (GAS). GAS is also an important cause of necrotizing fasciitis, for which an early and extensive surgical intervention is currently advocated. Here we report on the use of an aggressive medical regimen including high-dose IVIG together with a conservative surgical approach in severe GAS soft tissue infection. We describe 7 patients with severe soft tissue infection caused by GAS, who all were treated with effective antimicrobials and high-dose IVIG. Surgery was either not performed or only limited exploration was carried out. Six of the patients had toxic shock syndrome. All patients survived. Immunostaining of tissue biopsies from 2 of the patients revealed high levels of GAS, superantigen and pro-inflammatory cytokines initially, which were dramatically reduced in a repeat biopsy of the initial operative site collected from 1 of the patients 66 h post-IVIG administration. The study suggests that the use of a medical regimen including IVIG in patients with severe GAS soft tissue infections may allow an initial non-operative or minimally invasive approach, which can limit the need to perform immediate wide debridements and amputations in unstable patients.
authors.affiliation: Centre for Infectious Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden. anna.norrby-teglund@medhs.ki.se
authors.forename: Anna
authors.initials: A
authors.lastname: Norrby-Teglund
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Muller
authors.forename: Allison
authors.initials: A
authors.lastname: Mcgeer
authors.forename: Bing Siang
authors.initials: BS
authors.lastname: Gan
authors.forename: Veena
authors.initials: V
authors.lastname: Guru
authors.forename: John
authors.initials: J
authors.lastname: Bohnen
authors.forename: Pontus
authors.initials: P
authors.lastname: Thulin
authors.forename: Donald E
authors.initials: DE
authors.lastname: Low
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D019115:Fasciitis, Necrotizing / Q000188:drug therapy / Q000382:microbiology; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D012772:Shock, Septic / Q000188:drug therapy / Q000382:microbiology; D018461:Soft Tissue Infections / Q000382:microbiology / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D013290:Streptococcal Infections / Q000382:microbiology / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D013297:Streptococcus pyogenes / Q000187:drug effects / Q000302:isolation & purification; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D016756:Immunoglobulins, Intravenous