title: An early favorable outcome of streptococcal toxic shock syndrome may require a combination of antimicrobial and intravenous gamma globulin therapy together with activated protein C.
abstract: Streptococcal toxic shock syndrome (STSS) associated with a group A beta hemolytic streptococcal infection was described 18 y ago. Since then, although the pathophysiology of the syndrome has been clarified, mortality can be as high as 80%. A middle-aged female developed STSS associated with a group A streptococcal pneumonia. Laboratory studies confirmed respiratory and renal failure as well as disseminated intravascular coagulation with a striking reduction in endogenous procoagulants. The patient, probably due to her HLA DRB1*14 haplotype was unable to generate anti-streptococcal antibodies. She was treated with appropriate antimicrobial therapy together with intravenous gamma globulin and drotrecogin or activated protein C. Her response to this combined therapy was accompanied by a rapid resolution of the multiorgan failure and correction of the accompanying disseminated intravascular coagulation. This rapid response to treatment supports the hypohesis that several host factors including the immune response and loss of procoagulants determine the development and severity of the toxic shock syndromes. Further studies with this combined approach appear warranted.
authors.affiliation: Department of Medicine, Eisenhower Medical Center, Rancho Mirage, CA 92270, USA. laconemedico@AOL.com
authors.forename: Lawrence A
authors.initials: LA
authors.lastname: Cone
authors.forename: Richard A
authors.initials: RA
authors.lastname: Stone
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Schlievert
authors.forename: Ronald A
authors.initials: RA
authors.lastname: Sneider
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Rubin
authors.forename: Kenneth
authors.initials: K
authors.lastname: Jesser
authors.forename: Stacey W
authors.initials: SW
authors.lastname: Renker
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D003956:Dialysis; D004211:Disseminated Intravascular Coagulation / Q000188:drug therapy / Q000517:prevention & control; D005260:Female; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use*; D008875:Middle Aged; D011486:Protein C / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000627:therapeutic use; D012772:Shock, Septic / Q000188:drug therapy* / Q000382:microbiology; D013290:Streptococcal Infections / Q000150:complications / Q000188:drug therapy*; D013297:Streptococcus pyogenes / Q000187:drug effects / Q000472:pathogenicity*
chemical_list: D000890:Anti-Infective Agents; D016756:Immunoglobulins, Intravenous; D011486:Protein C; D011994:Recombinant Proteins; C421124:drotrecogin alfa activated