title: Spontaneous perforation of the cystic duct in streptococcal toxic shock syndrome: a case report.
abstract: BACKGROUND
  Streptococcal toxic shock syndrome is a complication of group A streptococcal infection, most often originating from the skin. The syndrome is characterized by fever, hypotension and multiple organ failure. Mortality rate may be as high as 80%.
  
  
  METHODS
  A 25-year-old man of Indian origin presented with abdominal complaints, rash and fever after an episode of pharyngitis. The patient was operated and a biliary peritonitis was found caused by perforation of the cystic duct in the absence of calculi. Cholecystectomy was performed, but after the operation, the patient's condition worsened and multi-organ failure developed. Group A streptococci were cultured in blood taken at admission and streptococcal toxic shock syndrome was diagnosed. Treatment consisted of antibiotics, corticosteroids, immunoglobulin and supportive treatment for haemodynamic, respiratory and renal failure.
  
  
  CONCLUSIONS
  This is a patient with streptococcal toxic shock syndrome complicated by spontaneous perforation of the cystic duct. Spontaneous perforation of the cystic duct is a rare finding, most often reported in children and secondary to anatomic defects. We found only one similar adult case in the literature. Perforation may be due to microthrombosis and ischaemia, and so be a part of the multi-organ failure often found in streptococcal toxic shock syndrome.
authors.affiliation: Onze Lieve Vrouwe Gasthuis, Department of Intensive Care Medicine, Amsterdam, the Netherlands. henrik.endeman@planet.nl
authors.forename: Henrik
authors.initials: H
authors.lastname: Endeman
authors.forename: David A
authors.initials: DA
authors.lastname: Ligtenstein
authors.forename: Heleen M
authors.initials: HM
authors.lastname: Oudemans-van Straaten