title: Unexplained persistent postpartum palpitations and tachycardia due to Group A Streptococcus.
abstract: BACKGROUND
  Group A Streptococcus is one of the most morbid infections in modern obstetric practice. Pregnant women are known to have a 20-fold increased risk of invasive Group A Streptococcus with greatest risk in the first 4 days postpartum. The overwhelming majority of these infections will present with fever, uterine tenderness, or vaginal discharge. A much smaller subset may present to the Emergency Room after initial hospital discharge with much less obvious symptoms. In our case, persistent palpitations with unexplained tachycardia led to improper diagnosis in multiple Emergency Rooms.
  
  
  METHODS
  A 37 year-old Caucasian female presents with four post-partum days of unexplained sinus tachycardia and absence of fever, uterine tenderness, or vaginal discharge, which elicits an extensive cardiac and pulmonary workup in multiple Emergency Rooms. Consequent late diagnosis of invasive Group A Streptococcus infection lead to significantly increased morbidity including toxic shock syndrome, acute renal failure, total abdominal hysterectomy and bilateral salpingo-oophorectomy, multiple laparotomies, fasciotomy, intubation, continuous renal replacement therapy, and extensive hospital course and recovery.
  
  
  CONCLUSIONS
  Persistent palpitations with unexplained tachycardia in the post-partum patient in the Emergency Room setting is a potential early warning of Group A Streptococcus infection. Even in the absence of reported clinical fever, uterine tenderness, or vaginal discharge, an early speculum and pelvic exam, with or without consultation with the obstetrics service, is prudent due to the potentially high morbidity or even fatality of Group A Streptococcus infection.
authors.affiliation: Department of Obstetrics and Gynecology, Albany Medical Center, 16 New Scotland Avenue, Second Floor, MC-74, Albany, NY, 12208, USA. kellern@mail.amc.edu.
authors.forename: Nathan A
authors.initials: NA
authors.lastname: Keller
authors.affiliation: Albany Medical College, 43 New Scotland Avenue, Albany, NY, 12208, USA. GuanX@mail.amc.edu.
authors.forename: Xin
authors.initials: X
authors.lastname: Guan
authors.affiliation: Department of Obstetrics and Gynecology, Albany Medical Center, 16 New Scotland Avenue, Second Floor, MC-74, Albany, NY, 12208, USA. wiczula@mail.amc.edu.
authors.forename: Alicia
authors.initials: A
authors.lastname: Wiczulis
authors.affiliation: Department of Obstetrics and Gynecology, Albany Medical Center, 16 New Scotland Avenue, Second Floor, MC-74, Albany, NY, 12208, USA. BurcheP@mail.amc.edu.
authors.forename: Paul
authors.initials: P
authors.lastname: Burcher
mesh_terms: D000328:Adult; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D005260:Female; D006321:Heart / Q000503:physiopathology*; D006801:Humans; D049590:Postpartum Period / Q000502:physiology*; D012772:Shock, Septic / Q000175:diagnosis; D013290:Streptococcal Infections / Q000175:diagnosis / Q000382:microbiology / Q000503:physiopathology*; D013297:Streptococcus pyogenes / Q000302:isolation & purification* / Q000502:physiology; D013610:Tachycardia / Q000382:microbiology / Q000503:physiopathology*