478: REFRACTORY TOXIC SHOCK SYNDROME: IV IMMUNOGLOBULIN TO THE RESCUE!

Abstract

Introduction: Streptococcal toxic shock syndrome (TSS) is one of the most severe manifestations of Group A Streptococcus (GAS). Despite adequate treatment, morbidity and mortality still remains high. We present a case of necrotizing fasciitis complicated by streptococcal TSS that was refractory to standard treatment and was ultimately treated successfully with intravenous immunoglobulin (IVIG). Description: A 63-year-old female with history of hypertension, morbid obesity and asthma presented to ED with a 1-week history of fever, malaise, and left thigh pain (no history of leg injury). Upon evaluation, patient’s left leg was noted to have multiple scabs and warmth in the left inguinal area. MRI of the left femur showed severe superficial and deep edema with cellulitis, concerning for necrotizing fasciitis. Labs were remarkable for leukocytosis 16.6 k/uL, creatinine 2.28 mg/dL and lactate 6 mmol/L. She received fluid resuscitation and was initiated on empiric antibiotic therapy with clindamycin, piperacillin-tazobactam and vancomycin. She had a rapid hemodynamic deterioration and required intubation and multiple vasopressors. She was taken to OR for emergent debridement and was admitted to the ICU postoperatively. Wound cultures were found positive for GAS and the diagnosis of STSS was made. Despite multiple wound debridement and amikacin therapy, patient failed to improve clinically. The decision was made to administer intravenous immunoglobulin as a rescue therapy. She was premedicated with diphenhydramine, hydrocortisone, and acetaminophen. She received IVIG at 1 g/kg/day for 1 day followed by 0.5 g/kg for another 2 days. The patient showed significant improvement post IVIG therapy and was subsequently transferred to the regular nursing floor after a few days. Discussion: Necrotizing fasciitis from GAS with streptococcal TSS has a very high mortality rate. Treatment includes aggressive wound debridement with gram positive and negative antibiotic coverage. Clindamycin is also used to inhibit toxin production. IVIG can be effective in treating TSS refractory to conventional treatment by neutralizing superantigens. The efficacy of IVIG in treating TSS has been variable across multiple studies, but our case highlights the efficacy of IVIG in toxic shock syndrome refractory to standard therapy.