A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

Abstract

SESSION TITLE: Remarkable Critical Care CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: Bacterial super-antigen induced T-lymphocyte and cytokine activation can cause multi-organ failure known as toxic shock syndrome(TSS). Acquiring the bacteria through a vaginal contraceptive device or pharyngeal infection has been reported. We present a case of Group A Streptococcus(GAS) related TSS resulting in multi-organ failure, lower extremity myonecrosis, pulmonary emboli and gastrointestinal bleeding in the setting of both foci of infection.CASE PRESENTATION: A 23 year old female with history of vaginal contraceptive ring placement presented to the hospital after 5 days of fever, cough, vomiting and diarrhea. She noted sick contact resulting in recent strep throat infection as well as concurrent use of tampons with a vaginal contraceptive ring. Upon arrival, she was hypotensive and febrile with a rectal temperature of 39.6. Physical exam was notable for mottled lower extremities with no palpable pulses and violaceous changes consistent with purpura fulminans. Lab-work revealed a lactic acid >15, platelet count of 18,000, and elevated creatine kinase(CK). Cardiac workup revealed cardiomyopathy/myocarditis. She was also anuric and determined to have disseminated intravascular coagulation(DIC). Blood cultures were noted to grow Group A Streptococcus Pyogenes. She was subsequently diagnosed with TSS. Her vaginal contraceptive ring was removed. She was intubated. Broad spectrum antibiotics and intravenous immunoglobulins(IVIG) were initiated. Her renal failure necessitated continuous renal replacement therapy along with vasopressors. Despite these interventions, she continued to deteriorate clinically. A CT Torso w/ IV contrast was completed which found bilateral pulmonary emboli(PE). A lower extremity angiogram revealed diffuse subcutaneous edema and air within the soft tissue and muscles. Flow was evident to the level of the popliteal artery but ceased at the tibial vessels. She was taken for emergent guillotine bilateral lower extremity amputation. Her hospital course was further complicated by an acute upper gastrointestinal bleed. An inferior vena cava(IVC) filter was placed for her PE. Her infectious burden and toxin load eventually responded to antibiotics, IVIG therapy and radical skin excision.DISCUSSION: Streptococcal TSS has been associated with both pharyngitis and gynecologic infections. Although it is unclear which preceded, the toxoid load proved to have significant morbidity. Despite removal of the contraceptive ring, guillotine amputation of her lower extremities may have been life saving as it appeared to eliminate a large toxoid focus.CONCLUSIONS: Toxin-neutralizing antibodies and broad spectrum antibiotics can reduce disease burden however the source of toxin secretion must be targeted. Obtaining hemodynamic stability and source control may be difficult when toxin burden involves a large surface area and has progressed to necrotizing fasciitis.Reference #1: Norrby-Teglund A, Muller MP, Mcgeer A, Gan BS, Guru V, Bohnen J, Thulin P, Low DE. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis. 2005;37(3):166-72. doi: 10.1080/00365540410020866. PMID: 15849047.Reference #2: Celie KB, Colen DL, Kovach SJ 3rd. Toxic Shock Syndrome after Surgery: Case Presentation and Systematic Review of the Literature. Plast Reconstr Surg Glob Open. 2020 May 29;8(5):e2499. doi: 10.1097/GOX.0000000000002499. PMID: 33133879; PMCID: PMC7572075.DISCLOSURES: No relevant relationships by Chanel FernandezNo relevant relationships by Erin GouldNo relevant relationships by Ariba HashmiNo relevant relationships by Anna Jacquinot SESSION TITLE: Remarkable Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Bacterial super-antigen induced T-lymphocyte and cytokine activation can cause multi-organ failure known as toxic shock syndrome(TSS). Acquiring the bacteria through a vaginal contraceptive device or pharyngeal infection has been reported. We present a case of Group A Streptococcus(GAS) related TSS resulting in multi-organ failure, lower extremity myonecrosis, pulmonary emboli and gastrointestinal bleeding in the setting of both foci of infection. CASE PRESENTATION: A 23 year old female with history of vaginal contraceptive ring placement presented to the hospital after 5 days of fever, cough, vomiting and diarrhea. She noted sick contact resulting in recent strep throat infection as well as concurrent use of tampons with a vaginal contraceptive ring. Upon arrival, she was hypotensive and febrile with a rectal temperature of 39.6. Physical exam was notable for mottled lower extremities with no palpable pulses and violaceous changes consistent with purpura fulminans. Lab-work revealed a lactic acid >15, platelet count of 18,000, and elevated creatine kinase(CK). Cardiac workup revealed cardiomyopathy/myocarditis. She was also anuric and determined to have disseminated intravascular coagulation(DIC). Blood cultures were noted to grow Group A Streptococcus Pyogenes. She was subsequently diagnosed with TSS. Her vaginal contraceptive ring was removed. She was intubated. Broad spectrum antibiotics and intravenous immunoglobulins(IVIG) were initiated. Her renal failure necessitated continuous renal replacement therapy along with vasopressors. Despite these interventions, she continued to deteriorate clinically. A CT Torso w/ IV contrast was completed which found bilateral pulmonary emboli(PE). A lower extremity angiogram revealed diffuse subcutaneous edema and air within the soft tissue and muscles. Flow was evident to the level of the popliteal artery but ceased at the tibial vessels. She was taken for emergent guillotine bilateral lower extremity amputation. Her hospital course was further complicated by an acute upper gastrointestinal bleed. An inferior vena cava(IVC) filter was placed for her PE. Her infectious burden and toxin load eventually responded to antibiotics, IVIG therapy and radical skin excision. DISCUSSION: Streptococcal TSS has been associated with both pharyngitis and gynecologic infections. Although it is unclear which preceded, the toxoid load proved to have significant morbidity. Despite removal of the contraceptive ring, guillotine amputation of her lower extremities may have been life saving as it appeared to eliminate a large toxoid focus. CONCLUSIONS: Toxin-neutralizing antibodies and broad spectrum antibiotics can reduce disease burden however the source of toxin secretion must be targeted. Obtaining hemodynamic stability and source control may be difficult when toxin burden involves a large surface area and has progressed to necrotizing fasciitis. Reference #1: Norrby-Teglund A, Muller MP, Mcgeer A, Gan BS, Guru V, Bohnen J, Thulin P, Low DE. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis. 2005;37(3):166-72. doi: 10.1080/00365540410020866. PMID: 15849047. Reference #2: Celie KB, Colen DL, Kovach SJ 3rd. Toxic Shock Syndrome after Surgery: Case Presentation and Systematic Review of the Literature. Plast Reconstr Surg Glob Open. 2020 May 29;8(5):e2499. doi: 10.1097/GOX.0000000000002499. PMID: 33133879; PMCID: PMC7572075. DISCLOSURES: No relevant relationships by Chanel Fernandez No relevant relationships by Erin Gould No relevant relationships by Ariba Hashmi No relevant relationships by Anna Jacquinot