Emerging infection: streptococcal toxic shock-like syndrome caused by group B Streptococcus (GBS), <i>Streptococcus agalactiae</i>

Rajack, Fareed; Medford, Shawn; Ramadan, Ali; Naab, Tammey

doi:10.4322/acr.2024.497

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Autopsy Case Report • Autops. Case Rep. 14 • 2024 • https://doi.org/10.4322/acr.2024.497 copy

Emerging infection: streptococcal toxic shock-like syndrome caused by group B Streptococcus (GBS), Streptococcus agalactiae

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Streptococcus agalactiae or Group B Streptococcus (GBS) infections are commonly associated with infections in neonates and pregnant women. However, there has been a rising incidence in nonpregnant adults. The risk of GBS infection in nonpregnant adults is increased for patients of advanced age and those with underlying medical conditions such as diabetes mellitus and cancer. We present a 77-year-old female with type-2 diabetes mellitus, hypertension, and bilateral foot ulcers that presented in probable septic shock with necrotic foot ulcers and necrotizing fasciitis and underwent bilateral lower limb amputations. The patient fulfilled the Streptococcal Toxic Shock Syndrome (STSS) criteria as defined by The Working Group on Severe Streptococcal Infections. These criteria were created for group A Streptococcus (Streptococcus pyogenes). Our patient fulfilled the Working Group’s criteria, except that the blood culture was positive for group B Streptococcus (Streptococcus agalactiae). Numerous studies demonstrate the importance of early detection and antibiotic treatment for GBS infections in general and early surgical management for necrotizing soft tissue infections (NSTIs) such as necrotizing fasciitis.

Keywords:
Amputation, Surgical; Bacteremia; Fasciitis, Necrotizing; Shock, Septic; Virulence Factors

Criteria	Working Group on Severe Streptococcal Infections' Proposed Case Definition	Patient Case
I	GAS isolation
IA	GAS isolation from a normally sterile site	GBS isolation from a normally sterile site (blood)
IB	GAS isolation from a normally non-sterile site
II	Indicators of severe infection (i.e., shock and organ system involvement)
IIA	Hypotension: Systolic blood pressure ≤ 90 mmHg (adults) or < 5th percentile for age (children)	Systolic blood pressure between 40-70 mm Hg
	AND
IIB	≥ 2 signs:
IIB1	Renal impairment: creatinine ≥ 2mg/dL for adults or ≥ 2 times the upper limit of normal for age	Creatinine: 2.47 mg/dL
IIB2	Coagulopathy: platelets ≤ 100 x 10⁹/L or disseminated intravascular coagulation	Platelets: 25 x 10⁹/L, Prothrombin time (PT): 82.9 sec (Reference: 12.5-14.5 sec), International normalized ratio (INR): 9.67 (Reference: 1.12-1.46) Partial thromboplastin time (PTT): 44.5 sec (Reference: 25.0-35.0 sec)
IIB3	Liver involvement: ALT, AST, or total bilirubin ≥ 2 times the upper limit of normal for age or ≥ 2 times baseline for preexisting liver disease	Alanine aminotransferase (ALT): 1,471 U/L Aspartate aminotransferase (AST): 7,359 U/L
IIB4	Acute respiratory distress syndrome, diffuse capillary leak, or pleural/peritoneal effusions with hypoalbuminemia
IIB5	Generalized erythematous macular rash (may desquamate)	Widespread erythematous rash
IIB6	Soft-tissue necrosis (e.g., necrotizing fasciitis, myositis, gangrene)	Necrotizing fasciitis

Criteria	Patient
SIRS (≥2 meets criteria)
Temp >38°C or <36°C	Temp 35.9°C (Day 0)
HR >90/min	HR up to 178/min (Day 0)
WBC >12,000/mm³, <4,000/mm³, or >10% bands	WBC 28.59x103 cells/mm³ (Day 0)
Sepsis (SIRS + Source of Infection)
Suspected/present infection source	Two blood cultures positive for GBS (Day 0)
Severe Sepsis (Organ Dysfunction, Hypotension, or Hypoperfusion)
Lactic acidosis, SBP <90 or SBP drop ≥40 mm Hg of normal	SBP 40-70 mmHg (Day 1)
Septic Shock
Severe sepsis with hypotension, despite fluid resuscitation	SBP 85 mmHg (Day 2)
Multiple Organ Dysfunction Syndrome
Evidence of ≥2 organs failing	Cr 2.47 mg/dL and AST 7359 U/L (Day 3)

	RR	Day 0	Day 1	Day 2	Day 3
Partial thromboplastin time (R)	25.0-35.0	32.6	41.7	44.9	44.5
Prothrombin time INR	1.12-1.46	1.42	2.58	3.2	9.67
Platelets (10⁹/L)	177-406	245	263	132	25
Hemoglobin (g/dL)	14.6-17.8	6.8	9.4	9.0	5.4
Leukocytes (10³/µL)	3.2-10.6	23.17	28.52	22.01	46.21
Creatinine (mg/dL)	0.6-1.2	0.69	0.63	1.37	2.47
Aspartate aminotransferase (U/L)	0-50	8		7467	7359
Alanine aminotransferase (U/L)	0-55	8		1217	1471

Hospital Universitário da Universidade de São Paulo Hospital Universitário da Universidade de São Paulo, Av. Prof. Lineu Prestes, 2565 - Cidade Universitária, 05508-000 - São Paulo - SP - Brasil, (16) 3307-2068, (16) 3307-2068 - São Paulo - SP - Brazil
E-mail: autopsy.hu@gmail.com

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[1] Conflict of interest: None