title: Right in Front of Our Eyes: Evolution of Streptococcal Toxic Shock Syndrome with Ischemic Optic Neuropathy.
abstract: BACKGROUND
  Toxic shock syndrome occurs from dysregulation of host inflammatory responses. Toxin- producing strains of Group A streptococcus cause TSS. Ischemic optic neuropathy rarely complicates septic shock. We present a rare case of streptococcal pharyngitis complicated by septic arthritis and TSS with reversible blindness due to non-arteritic ischemic optic neuropathy.
  
  
  METHODS
  A 28-year-old man drove to our ED with exudative pharyngitis. A rapid streptococcal test was positive. While awaiting oral penicillin he became hypotensive refractory to IV fluids and developed knee effusion. The patient noted progressive dimming of his vision. Arthrocentesis yielded GAS. ICU course was complicated by ARDS but after 2 weeks the patient was weaned off vasopressors and the ventilator. He regained his vision and had no neurological sequelae. The patient's GAS isolate was M protein gene (emm) type 1 and T type 1. He was followed in the IM clinic for 9 months post discharge with complete resolution of symptoms.
  
  
  CONCLUSIONS
  The rapidity of the development of shock is attributed to streptococcal exotoxins acting as superantigens. GAS type M1 is commonly associated with severe shock in TSS. The severe shock was the likely cause of his ischemic optic neuropathy. Early recognition and aggressive management of TSS are crucial to clinical outcome. [Full article available at http://rimed.org/rimedicaljournal-2016-12.asp].
authors.affiliation: Department of Medicine, Memorial Hospital of Rhode Island, Alpert Medical School of Brown University.
authors.forename: Salaheldin M
authors.initials: SM
authors.lastname: Elhamamsy
authors.affiliation: Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, Alpert Medical School of Brown University.
authors.forename: Mazen O
authors.initials: MO
authors.lastname: Al-Qadi
authors.affiliation: Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, Alpert Medical School of Brown University.
authors.forename: Taro
authors.initials: T
authors.lastname: Minami
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Memorial Hospital of Rhode Island, Alpert Medical School of Brown University.
authors.forename: Marguerite
authors.initials: M
authors.lastname: Neill
mesh_terms: D000328:Adult; D001766:Blindness / Q000209:etiology; D005098:Exotoxins / Q000009:adverse effects*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D018917:Optic Neuropathy, Ischemic / Q000209:etiology*; D010612:Pharyngitis / Q000150:complications*; D012772:Shock, Septic / Q000150:complications* / Q000628:therapy; D013290:Streptococcal Infections / Q000150:complications*; D013297:Streptococcus pyogenes / Q000302:isolation & purification*
chemical_list: D005098:Exotoxins
keywords: Group A streptococcus; Staphylococcus aureus; TSS; Toxic shock syndrome