(579) Stop the GAS: IVIg for Streptococcal Toxic Shock From an Empyema

Introduction: Streptococcal toxic shock syndrome (TSS) is a severe manifestation of invasive group A Streptococcus (GAS) infection, and may lead to hemodynamic compromise, multi-organ failure, and mortality. Soft tissue infections are common; however, GAS may also cause empyema, septic arthritis and peritonitis. This case reviews a patient with antibiotic-refractory TSS due to a GAS empyema who was successfully treated with intravenous immunoglobulin (IVIG).

Description: A 64-year-old male with hypertension presented with hypoxia and flu-like symptoms. Initial labs were remarkable for a WBC of 51.3 k/mm3, lactate of 8.1 mmol/L and SCr of 4.56 mg/dL. Despite fluid resuscitation, patient required norepinephrine to maintain blood pressure and ceftriaxone was initiated for septic shock. Due to increasing oxygen requirements and lactate, he was admitted to the ICU, intubated and placed on CRRT. On Day 1, chest CT revealed a left sided empyema, and a chest tube was placed, draining 2000 mL of purulent fluid. The respiratory PCR became positive for enterovirus and blood and pleural fluid cultures grew GAS. Linezolid was added in the setting of TSS, and infectious diseases was consulted. Despite appropriate antimicrobials, patient further decompensated on day 2 becoming febrile and requiring the addition of epinephrine, vasopressin, hydrocortisone, and a methylene blue infusion. Given lack of improvement with antibiotics, IVIG was initiated at 1 mg/kg on Day 2, then 0.5 mg/kg on Days 3 and 4. Within 48 hours of completing IVIG, patient was weaned off vasopressors and extubated and later discharged to inpatient rehab.

Discussion: Standard therapy for GAS manifesting as TSS involves an anti-streptococcal agent plus a toxin suppressing antibiotic. Morbidity and mortality with TSS are high, and clinicians are left with few options for patient’s refractory to standard therapy. Patients with TSS may have lower levels of protective antibodies against superantigens produced by GAS. IVIG is thought to provide a neutralizing effect. Several small studies display a trend toward reducing mortality with IVIG, but few have shown statistical significance. A unique case is highlighted involving antibiotic-refractory TSS resulting from GAS from an empyema with a successful recovery following administration of IVIG.