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Sepsis Management in a Young Physician: Case Study and Insights on Group A Streptococcus

This case study presents a 40-year-old neurologist exhibiting severe muscle myalgias, fever, and respiratory distress, ultimately diagnosed with Group A Streptococcal (GAS) sepsis. Initial treatment included ceftriaxone and moxifloxacin, with subsequent identification of beta-hemolytic streptococci. The patient's hospital course was complicated by cardiac arrest, but with aggressive therapy, including clindamycin and intravenous immunoglobulin (IVIG), he recovered. This case emphasizes the need for prompt diagnosis and effective adjunctive therapies in severe GAS infections.

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Sepsis Management in a Young Physician: Case Study and Insights on Group A Streptococcus

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  1. Sepsis In A Young Physician March 31, 2004 Edward L. Goodman, MD

  2. Outline • Case Presentation • Differential Diagnosis • Hospital Course • Epidemiology • Adjunctive Therapy

  3. History • CC: Fever and myalgias • HPI: 40 year old neurologist • Six days of progressive large muscle myalgias • Three days of mild cough mildly productive • Mild dyspnea, no pleurisy • Self administered amantadine for presumed influenza

  4. History 2 • ROS: no recent sore throat, no CNS symptoms, no GI or GU sx • PMH: unremarkable except for frequent flu like illnesses for which he takes amantadine and NSAIDs • Epidemiology: twins age 15 month, not in daycare, recent travel to California where exposed to two other young children

  5. Exam • Very ill and toxic appearing • Temp very elevated, HR 120, BP 115/73 • Injected conjunctivae without petechiae • Supple neck • Diffuse erythema on trunk • Few petechiae on legs • Few rales LLL, gallop rhythm • Tender muscles

  6. Initial Chest X Ray

  7. Initial Lab • pH 7.4, pCO2 33.8, pO2 58 on RA • Mixed acid base disorder • WBC 8500, 53% bands • Platelets 158,000 • INR 1.7, PTT 48.7, d dimer 537 • Creat 1.0, Alk ptase 173, AST/ALT 48/121, Bili 3.7 (direct 2.6), CRP 23.1

  8. Differential Diagnosis • Focal infiltrates - Community Acquired Pneumonia, post influenza pneumonia • Severe Myalgias • Influenza: proper season • Dengue: no travel to tropics • Leptospirosis: no exposure to rats, cattle, dogs • Petechiae, septic, infiltrate: • meningococci

  9. Hospital Course • Started on Ceftriaxone and Moxifloxacin for possible CAP, meningococcemia • Transfer to ICU for deteriorating BP, pulmonary status • Blood cultures positive at 12 hours for GPC in pairs and chains = likely Strept pneumo?

  10. Next Day: 2/23/04 • 0600 blood cultures are beta hemolytic • Not Strept pneumo! • One dose Vancomycin • Added Clindamycin • Started Xigris • On vent 100% FiO2 • Multiple pressors • Survival seems unlikely

  11. Third Day: 2/24/04 • Group A Strept confirmed • Added IVIG • Multiple pressors and 100% FiO2 still • Cardiac arrest – resuscitated • Hung crepe with family

  12. Subsequent CXR2/26/04

  13. Subsequent Course • Blisters on leg develop and evolve • Vascular surgeon recommends against debridement • Gradually rallies • Pressors tapered • Vent tapered • MOF reversed • Discharged to Rehab 3/15/04 • Home 3/22/04!

  14. Initial Lab • pH 7.4, pCO2 33.8, pO2 58 on RA • Mixed acid base disorder • WBC 8500, 53% bands • Platelets 158,000 • INR 1.7, PTT 48.7, d dimer 537 • Creat 1.0, Alk ptase 173, AST/ALT 48/121, Bili 3.7 (direct 2.6), CRP 23.1

  15. Peak Lab Abnormalities

  16. Skin Lesions First Day

  17. Evolving Lesions

  18. Desquamation Day 16

  19. Recent Film: 3/8/04

  20. Epidemiology of Invasive GSS

  21. Epidemiology

  22. Discussion • Antibiotics • Penicillin • Clindamycin • Role of IVIG

  23. Penicillin’s ineffectiveness • High mortality in invasive GAS when Penicillin used • 81% mortality in myositis • Animal data on inoculum effect • High concentrations of GAS in deep sites • Stationary phase reached quickly • PBPs not expressed in stationary phase

  24. Clindamycin • No inoculum effect • Suppresses toxin synthesis • Facilitates phagocytosis by inhibiting M protein synthesis • Suppresses proteins involved in cell wall synthesis • Longer post antibiotic effect (PAE) • Suppress LPS induced monocyte synthesis of TNF-alpha

  25. TSS and IVIG • Shock from gram positive toxins • Superantigens • Enterotoxins • TSST-1 • SPEA • Superantigens bind to • MHC II • ß chain of T cell receptor • Resulting in • T cell proliferation • Cytokine production

  26. IVIG • Blocks in vitro T cell activation • Contains superantigen neutralizing antibodies

  27. Effects of IVIGKaul et al, CID 1999;28:800

  28. Conclusion • Severe pain and fever – think of GAS • Know the epidemiology of your institution • Consult a surgeon promptly if skin or muscle involvement • Add Clindamycin to beta lactam therapy for necrotizing or serious GAS infections • Consider IVIG for TSS • Consider Xigris

  29. References • Bisno AL, Stevens DL. Streptococcal Infections of Skin and Soft Tissues. New Eng J Med 1996; 334:240-245. • Case Records of the MGH. New Eng J Med 1995; 333: 113-119. • Case Records of the MGH. New Eng J Med 2002; 347:831-837. • Disease Prevention News. TDH. March 27, 2000;60: No.7. • Kaul R, McGeer A et al. Intravenous Immunoglobulin Therapy for Streptococcal Toxic Shock Syndrome – A Comparative Observational Study. Clin Infect Dis 1999; 28:800-807.

  30. References - continued • Kazatchkine MD, Kaveri, SV. Immunomodulation of Autoimmune and Inflammatory Diseases with Intravenous Immune Globulin. New Eng J Med 2001; 345: 747-755. • Stevens DL. The Flesh-Eating Bacterium: What’s Next. J Infect Dis 1999;179(Suppl 2): S366-374

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