Case history
Case history
A 32-year-old woman presents to the emergency department with complaints of fever, chills, headache, muscle aches, and shortness of breath over the past 48 hours. Two weeks before her symptoms, she had an uncomplicated vaginal delivery at term. She has no significant past medical history. No one else at home has been recently sick or traveled outside the country. On physical exam she appears toxic with a temperature of 103.1°F (39.5°C). Her pulse rate is 132 bpm and her BP is 100/60 mmHg with a respiratory rate of 34 breaths/minute. A diffuse erythematous rash is noted on the upper and lower extremities. Breath sounds are diminished at the bases. The rest of the exam is noncontributory.
Other presentations
Severe group A streptococcal infections can result in infections including bacteremia, cellulitis, meningitis, pneumonia, empyema, peritonitis, septic arthritis, puerperal sepsis, burn wound sepsis, necrotizing fasciitis, and gangrenous myositis.[9] These infections can present with evidence of toxic shock syndrome (TSS) with shock and multiorgan system failure. Some atypical presentations have been reported, such as secondary infections with group A streptococcus as a result of a primary varicella infection. Although varicella infection is often a self-limited infection in children, it can be associated with serious life-threatening infections in both immunocompetent and immunocompromised patients. Serious bacterial infections caused by group A streptococcal infections are increasing in frequency as a complication of varicella.[10][11]
Recurrent menstrual and nonmenstrual staphylococcal TSS have been reported, and are seen primarily in those patients who have not been treated with appropriate antistaphylococcal antibiotics or for adequate duration of therapy.[12][13][14][15] Up to one third of patients may have recurrent menstrual TSS, particularly those patients who do not develop a humoral response to the staphylococcal toxin and/or have persistent colonization with a toxigenic strain of Staphylococcus aureus.[12][14][16] Recurrent nonmenstrual cases can occur when patients do not develop a protective level of antibody in the convalescent phase after the initial infection.[15] Recurrences can occur from days to months after the initial presenting syndrome. In menstrual TSS, recurrences are generally milder than the initial disease.
A variant of staphylococcal TSS has also been described in patients with AIDS, presenting as a subacute illness with desquamation, erythroderma, mucocutaneous infections, and hypotension, all of which persist or recur over several weeks.[17]
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