Resurgence of Severe Group A Streptococcus Infections

1
Resurgence of Severe Group A Streptococcus
Infections
Kathryn J. Sowerwine, MD Ram Srinivasan, MD
Princy N. Kumar, MD
Department of Medicine, Georgetown University
Hospital, Washington, DC Georgetown University
Medical Center, Washington, DC
Georgetown University
Case 2
Abstract

• 29 y/o previously healthy Korean F with no
  significant past medical history transferred to
  GUH for respiratory failure and sepsis
• Symptoms started 1 week prior to admission with
  nausea, vomiting, malaise which progressed to
  cough and severe SOB
• Physical Exam
• Notable for severe respiratory distress at
  outside hospital (OSH)
• Hypotension
• Diffuse rhonchi
• Significant Labs
• WBC 12.2 Platelets 110,000
• Na 132 PTT 42.3 INR 1.44 PT 17.4
• CXR reveal right sided pneumonia (Picture 4)
• Intubated and placed on stress dose steroids,
  pressors and transferred to GUH
• Antibiotics on arrival from OSH were vancomycin,
  ceftriaxone, clindamycin, and azithromycin.
• Blood culture from OSH were 4/4 bottles GAS,
  Streptococcus pyogenes
• On arrival to GUH antibiotics were changed to
  penicillin G 4 million units IV q4h, clindamycin
  and IVIG x 3 doses
• Right sided effusion was drained via chest tube

Group A streptococcus (GAS) infections can cause
serious life threatening illnesses. Predisposing
factors that are known include skin breakdown as
a source of entry, post URI, and chronic illness
such as CHF or DM.1 Healthy individuals are also
at risk for such infections. These infections can
cause devastating results as seen in the
following three cases. It is important to
recognize GAS infections early and to treat
appropriately in order to limit toxin production
and decrease morbidity and mortality. In 2006,
4,587 cases of severe GAS disease were reported
to the Centers for Disease Control and Prevention
(CDC).
Picture 4. Right sided pneumonia with effusion
C
Background
While on Infectious Disease elective February
2008 there were 4 cases of severe GAS infections.
Three of the cases were patients that had no
significant medical history and the last case was
an immunosuppressed patient that developed GAS
necrotizing fasciitis. This poster is dedicated
to the three previously healthy individuals with
GAS infections ranging from bacteremia with
pneumonia to full blown toxic shock meningitis
with purpura fulminans requiring 4 extremity
amputation.
Picture 5. Near complete consolidation of right
lung with minimal effusion
Case 3
Introduction

• 47 y/o WM with no significant past medical
  history except seizure disorder (on no meds last
  seizure 20 years ago) and hemorrhoids
• Presented to GUH with 1 week of high fevers,
  productive cough and fatigue. Positive sick
  contacts included his 2 children with recent URI.
  Brought to the hospital after collapsing onto
  one knee.
• Physical Exam
• Temp 40.6 C BP 146/77 RR 18 P 98 Pulse-ox 100
  RA
• Egophony RLL and inspiratory rhonci bilaterally
• Significant Labs
• WBC 12.6 N 87 Bands 4 ?increased to 27 Bands
  on Day 2
• Na 132
• Admitted for CAP was started on azithromycin and
  ceftrixone
• Sputum culture was positive for GAS
• Despite antibiotics patient continued to be
  febrile and CT scan was done which revealed a
  significant loculated pleural effusion (Picture
  7)
• On day 4 thoracic surgery was consulted and
  video-assisted thorascopic surgery decortication
  was preformed for empyema
• Infectious disease team saw patient on the day of
  surgery
• Antibiotics were changed to penicillin G 4
  million units IV q4h and clindamycin.

• GAS has a complex interaction with ones immune
  system causing a range of diseases as seen in
  Figure 1.
• Clusters of GAS infections have been observed
• Daycare centers (Boston, Massachusetts 1997
  related to varicella)
• Army barracks (Ft. Gordon, GA ?8 cases Jan-April
  2007)
• Long term living facilities (January 2001 to
  October 2007 New York State? 35 cases with severe
  GAS infections)
• Hospital outbreaks
• Invasive GAS disease has increased since the
  mid-1980s virulence of the bacterium is based on
  which M protein is present and the host/humans
  own immune reaction to the superantigen which may
  be HLA related. 2 Serotypes M1 and M3 are known
  to be the most virulent.3

Picture 6. CXR showing RLL consolidation
Picture 7. CT scan on Day 3 showing loculated
pleural effusion
Figure 1. Types of GAS Infections9
Case 1
Picture 8. Four weeks after presentation with
complete resolution of empyema

• 62 y/o previously healthy WF transferred to GUH
  for presumed TTP
• Home meds included Ambien prn and Motrin prn
• Significant change in mental status and 2 week
  history of vaginal discharge associated with
  abdominal pain
• Physical Exam
• Temp 36C RR 40 BP 102/56 P 125 Pulse-ox
  undetectable
• notable for nuchal rigidity, petechial rash,
  purpura fulminans, and right thigh eschar
• Significant Labs
• WBC 2.3 Neut 44 Bands 41 Mono 10 Na 134
• Plat 28,000 BUN 67 Creatinine 3.6
• HCT 41.5 PTT 39.9 INR 1.3 PT 16
• Cortisol 110
• Peripheral smear-no schistocytes
• Started on ceftriaxone, vancomycin,
  dexamethasone, and ampicillin
• Infectious disease was consulted the evening of
  admission and added doxycycline for possible RMSF

Discussion
.
As seen through these three cases, GAS can be
very invasive and cause overwhelming disease in
healthy individuals. Toxic shock is associated
with 8-14 of cases.5 Case 1 was the only case
that met criteria for strep TSS. Treatment is
aimed at decreasing toxic production and
eliminating the immune cascade response.
Clindamycin is used to halt production of toxin
and works synergistically with penicillin to
eliminate the bacterium. IVIG is suggested as a
potential adjunctive therapy for invasive GAS
diseases due to its ability to neutralize a wide
variety of superantigens and to facilitate
opsonization of streptococci. Evidence for IVIG
is limited and mostly based on retrospective
chart reviews. 6,7 Even with aggressive
treatment, mortality remains 3050.5 In April
1995, invasive GAS infections and strep TSS were
added to the National Public Health Surveillance
System. The CDC was contacted regarding all four
cases that occurred in a 3 week period and an
investigation is ongoing.
Picture 1. Necrosis of fingertips
Conclusions
Picture 2. Purpura fulminans
Jim Henson -- creator of the Muppets is one
famous casualty from GAS. He, just like the
three cases presented, had no risk factors and
fell ill to the toxic effects of GAS. There are
vaccines currently under investigation that would
potentially eliminate the spectrum of disease
from GAS.8 More research is needed to understand
why certain individuals are more susceptible than
others. Awareness of severe GAS infections will
help with early recognition and treatment.
References

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  group A streptococcal infections. Nat Med
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• Journal Of The American Medical Association
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• http//www.nfsuk.org.uk/Information/strepa2.php
  The 'Lee Spark' NF Foundation.

Picture 3. Right thigh eschar and petechial rash