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. 1993 Feb;217(2):109–114. doi: 10.1097/00000658-199302000-00003

Streptococcal toxic shock-like syndrome. The importance of surgical intervention.

T F Wood 1, M A Potter 1, O Jonasson 1
PMCID: PMC1242748  PMID: 8439208

Abstract

Pyrogenic exotoxins A, B, and C produced by group A beta-hemolytic streptococci (Streptococcus pyogenes) may cause a syndrome characterized by fever, rash, desquamation, hypotension, and multi-organ-system dysfunction. This syndrome, the streptococcal toxic shock-like syndrome (TSLS), has a rapid and fulminant course closely resembling the staphylococcal toxic shock syndrome (TSS) caused by the staphylococcal toxic shock syndrome toxin-1 (TSST-1). The recent recognition of this syndrome is thought to stem from the appearance of more virulent strains of streptococci that have a greater tendency to produce potent exotoxins than prior strains. During the past 6 years, the authors have treated six patients with TSLS; three of these patients have presented recently. The sites of streptococcal infection associated with the development of the syndrome are frequently in soft tissue and skin. Early diagnosis, treatment with penicillin, and radical operative debridement are required.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bartter T., Dascal A., Carroll K., Curley F. J. 'Toxic strep syndrome'. A manifestation of group A streptococcal infection. Arch Intern Med. 1988 Jun;148(6):1421–1424. doi: 10.1001/archinte.148.6.1421. [DOI] [PubMed] [Google Scholar]
  2. Begovac J., Marton E., Lisić M., Beus I., Bozinović D., Kuzmanović N. Group A beta-hemolytic streptococcal toxic shock-like syndrome. Pediatr Infect Dis J. 1990 May;9(5):369–370. doi: 10.1097/00006454-199005000-00013. [DOI] [PubMed] [Google Scholar]
  3. Bergdoll M. S., Crass B. A., Reiser R. F., Robbins R. N., Davis J. P. A new staphylococcal enterotoxin, enterotoxin F, associated with toxic-shock-syndrome Staphylococcus aureus isolates. Lancet. 1981 May 9;1(8228):1017–1021. doi: 10.1016/s0140-6736(81)92186-3. [DOI] [PubMed] [Google Scholar]
  4. Bisno A. L. Group A streptococcal infections and acute rheumatic fever. N Engl J Med. 1991 Sep 12;325(11):783–793. doi: 10.1056/NEJM199109123251106. [DOI] [PubMed] [Google Scholar]
  5. Bradley J. S., Schlievert P. M., Sample T. G., Jr Streptococcal toxic shock-like syndrome as a complication of varicella. Pediatr Infect Dis J. 1991 Jan;10(1):77–79. doi: 10.1097/00006454-199101000-00017. [DOI] [PubMed] [Google Scholar]
  6. Brook M. G., Bannister B. A. Scarlet fever can mimic toxic shock syndrome. Postgrad Med J. 1988 Dec;64(758):965–967. doi: 10.1136/pgmj.64.758.965. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Chomarat M., Chapuis C., Lepape A., Bernard F. Two cases of severe infection with beta-haemolytic group A streptococci associated with a toxic-shock-like syndrome. Eur J Clin Microbiol Infect Dis. 1990 Dec;9(12):901–903. doi: 10.1007/BF01967508. [DOI] [PubMed] [Google Scholar]
  8. Christen R. D., Moser R., Schlup P., Neftel K. A. Fulminant group A streptococcal infections. Report of two cases. Klin Wochenschr. 1990 Apr 17;68(8):427–430. doi: 10.1007/BF01648585. [DOI] [PubMed] [Google Scholar]
  9. Cleary P. P., Kaplan E. L., Handley J. P., Wlazlo A., Kim M. H., Hauser A. R., Schlievert P. M. Clonal basis for resurgence of serious Streptococcus pyogenes disease in the 1980s. Lancet. 1992 Feb 29;339(8792):518–521. doi: 10.1016/0140-6736(92)90339-5. [DOI] [PubMed] [Google Scholar]
  10. Cone L. A., Woodard D. R., Schlievert P. M., Tomory G. S. Clinical and bacteriologic observations of a toxic shock-like syndrome due to Streptococcus pyogenes. N Engl J Med. 1987 Jul 16;317(3):146–149. doi: 10.1056/NEJM198707163170305. [DOI] [PubMed] [Google Scholar]
  11. Congeni B., Rizzo C., Congeni J., Sreenivasan V. V. Outbreak of acute rheumatic fever in northeast Ohio. J Pediatr. 1987 Aug;111(2):176–179. doi: 10.1016/s0022-3476(87)80063-x. [DOI] [PubMed] [Google Scholar]
  12. Connolly T. J., Pavelka D. J., Lanspa E. F., Connolly T. L. Toxic shock-like syndrome associated with necrotizing Streptococcus pyogenes infection. Henry Ford Hosp Med J. 1989;37(2):69–72. [PubMed] [Google Scholar]
  13. EAGLE H. Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice. Am J Med. 1952 Oct;13(4):389–399. doi: 10.1016/0002-9343(52)90293-3. [DOI] [PubMed] [Google Scholar]
  14. Fikrig E., Worthington M. T., Lefkowitz L. B., Jr Septic shock and acute respiratory distress syndrome after salpingitis caused by Streptococcus pyogenes group A. South Med J. 1989 May;82(5):634–635. doi: 10.1097/00007611-198905000-00024. [DOI] [PubMed] [Google Scholar]
  15. Gallo U. E., Fontanarosa P. B. Toxic streptococcal syndrome. Ann Emerg Med. 1990 Nov;19(11):1332–1334. doi: 10.1016/s0196-0644(05)82299-1. [DOI] [PubMed] [Google Scholar]
  16. Givner L. B., Abramson J. S., Wasilauskas B. Apparent increase in the incidence of invasive group A beta-hemolytic streptococcal disease in children. J Pediatr. 1991 Mar;118(3):341–346. doi: 10.1016/s0022-3476(05)82144-4. [DOI] [PubMed] [Google Scholar]
  17. Group A streptococcal infections and a toxic shock-like syndrome. N Engl J Med. 1989 Nov 30;321(22):1545–1547. doi: 10.1056/NEJM198911303212212. [DOI] [PubMed] [Google Scholar]
  18. Group A streptococcal infections and a toxic shock-like syndrome. N Engl J Med. 1989 Nov 30;321(22):1545–1547. doi: 10.1056/NEJM198911303212212. [DOI] [PubMed] [Google Scholar]
  19. Herold A. H. Group A beta-hemolytic streptococcal toxic shock from a mild pharyngitis. J Fam Pract. 1990 Nov;31(5):549–551. [PubMed] [Google Scholar]
  20. Hosier D. M., Craenen J. M., Teske D. W., Wheller J. J. Resurgence of acute rheumatic fever. Am J Dis Child. 1987 Jul;141(7):730–733. doi: 10.1001/archpedi.1987.04460070032015. [DOI] [PubMed] [Google Scholar]
  21. Hríbalová V. Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med. 1988 May;108(5):772–772. doi: 10.7326/0003-4819-108-5-772_2. [DOI] [PubMed] [Google Scholar]
  22. Ispahani P., Donald F. E., Aveline A. J. Streptococcus pyogenes bacteraemia: an old enemy subdued, but not defeated. J Infect. 1988 Jan;16(1):37–46. doi: 10.1016/s0163-4453(88)96073-2. [DOI] [PubMed] [Google Scholar]
  23. Johnson L. P., L'Italien J. J., Schlievert P. M. Streptococcal pyrogenic exotoxin type A (scarlet fever toxin) is related to Staphylococcus aureus enterotoxin B. Mol Gen Genet. 1986 May;203(2):354–356. doi: 10.1007/BF00333979. [DOI] [PubMed] [Google Scholar]
  24. Kavey R. E., Kaplan E. L. Resurgence of acute rheumatic fever. Pediatrics. 1989 Sep;84(3):585–586. [PubMed] [Google Scholar]
  25. Knezevich S., Torch M. Streptococcal toxic shocklike syndrome leading to bilateral lower extremity compartment syndrome and renal failure. Report of a case. Clin Orthop Relat Res. 1990 May;(254):247–250. [PubMed] [Google Scholar]
  26. Lersch C., Gain T., von Siemens M., Hagenmüller F., Classen M. Toxic shock-like syndrome due to severe hemolytic group A streptococcal infection. Klin Wochenschr. 1990 May 17;68(10):523–525. doi: 10.1007/BF01648248. [DOI] [PubMed] [Google Scholar]
  27. Margolis D. J., Horlick S. E. Group A streptococcus-induced bullous toxic shock-like syndrome. J Am Acad Dermatol. 1991 May;24(5 Pt 1):786–787. doi: 10.1016/s0190-9622(08)80371-4. [DOI] [PubMed] [Google Scholar]
  28. McGlashan J. A. Do streptococci cause toxic shock? BMJ. 1990 Dec 15;301(6765):1391–1392. doi: 10.1136/bmj.301.6765.1391-a. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Musser J. M., Hauser A. R., Kim M. H., Schlievert P. M., Nelson K., Selander R. K. Streptococcus pyogenes causing toxic-shock-like syndrome and other invasive diseases: clonal diversity and pyrogenic exotoxin expression. Proc Natl Acad Sci U S A. 1991 Apr 1;88(7):2668–2672. doi: 10.1073/pnas.88.7.2668. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Paraskevaides E. C., Wilson M. C. Fatal disseminated intravascular coagulation secondary to streptococcal cervicitis. Eur J Obstet Gynecol Reprod Biol. 1988 Sep;29(1):39–40. doi: 10.1016/0028-2243(88)90163-3. [DOI] [PubMed] [Google Scholar]
  31. Schattner A., Hay E., Lifschitz-Mercer B., Gorbacz S., Bentwich Z. Fulminant streptococcal myositis. Ann Emerg Med. 1989 Mar;18(3):320–322. doi: 10.1016/s0196-0644(89)80423-8. [DOI] [PubMed] [Google Scholar]
  32. Schlievert P. M., Shands K. N., Dan B. B., Schmid G. P., Nishimura R. D. Identification and characterization of an exotoxin from Staphylococcus aureus associated with toxic-shock syndrome. J Infect Dis. 1981 Apr;143(4):509–516. doi: 10.1093/infdis/143.4.509. [DOI] [PubMed] [Google Scholar]
  33. Shaunak S., Wendon J., Monteil M., Gordon A. M. Septic scarlet fever due to Streptococcus pyogenes cellulitis. Q J Med. 1988 Nov;69(259):921–925. [PubMed] [Google Scholar]
  34. Shearin R. S., Boehlke J., Karanth S. Toxic shock-like syndrome associated with Bartholin's gland abscess: case report. Am J Obstet Gynecol. 1989 May;160(5 Pt 1):1073–1074. doi: 10.1016/0002-9378(89)90163-4. [DOI] [PubMed] [Google Scholar]
  35. States B., Segal S. Levels of gamma-glutamyltranspeptidase in cultured skin fibroblasts from cystinotics and normals. Life Sci. 1980 Nov 24;27(21):1985–1990. doi: 10.1016/0024-3205(80)90419-1. [DOI] [PubMed] [Google Scholar]
  36. Stevens D. L., Gibbons A. E., Bergstrom R., Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis. 1988 Jul;158(1):23–28. doi: 10.1093/infdis/158.1.23. [DOI] [PubMed] [Google Scholar]
  37. Stevens D. L., Tanner M. H., Winship J., Swarts R., Ries K. M., Schlievert P. M., Kaplan E. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989 Jul 6;321(1):1–7. doi: 10.1056/NEJM198907063210101. [DOI] [PubMed] [Google Scholar]
  38. Stollerman G. H. Changing group A streptococci. The reappearance of streptococcal 'toxic shock'. Arch Intern Med. 1988 Jun;148(6):1268–1270. doi: 10.1001/archinte.148.6.1268. [DOI] [PubMed] [Google Scholar]
  39. Stollerman G. H. Global changes in group A streptococcal diseases and strategies for their prevention. Adv Intern Med. 1982;27:373–406. [PubMed] [Google Scholar]
  40. Todd J., Fishaut M., Kapral F., Welch T. Toxic-shock syndrome associated with phage-group-I Staphylococci. Lancet. 1978 Nov 25;2(8100):1116–1118. doi: 10.1016/s0140-6736(78)92274-2. [DOI] [PubMed] [Google Scholar]
  41. Veasy L. G., Wiedmeier S. E., Orsmond G. S., Ruttenberg H. D., Boucek M. M., Roth S. J., Tait V. F., Thompson J. A., Daly J. A., Kaplan E. L. Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med. 1987 Feb 19;316(8):421–427. doi: 10.1056/NEJM198702193160801. [DOI] [PubMed] [Google Scholar]
  42. Wald E. R., Dashefsky B., Feidt C., Chiponis D., Byers C. Acute rheumatic fever in western Pennsylvania and the tristate area. Pediatrics. 1987 Sep;80(3):371–374. [PubMed] [Google Scholar]
  43. Wheeler M. C., Roe M. H., Kaplan E. L., Schlievert P. M., Todd J. K. Outbreak of group A streptococcus septicemia in children. Clinical, epidemiologic, and microbiological correlates. JAMA. 1991 Jul 24;266(4):533–537. [PubMed] [Google Scholar]
  44. Whitted R. W., Yeomans E. R., Hankins G. D. Group A beta-hemolytic Streptococcus as a cause of toxic shock syndrome. A case report. J Reprod Med. 1990 May;35(5):558–560. [PubMed] [Google Scholar]
  45. Willoughby R., Greenberg R. N. The toxic shock syndrome and streptococcal pyrogenic exotoxins. Ann Intern Med. 1983 Apr;98(4):559–559. doi: 10.7326/0003-4819-98-4-559_1. [DOI] [PubMed] [Google Scholar]

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