Severe Group A Streptococcal Toxic Shock Syndrome after Total Thyroidectomy

Authors:
Christine Cocanour, Michael Campbell, Sarah Lucente

Body of Abstract:
Background: Group A streptococcal (GAS) infection with toxic shock syndrome (TSS) is a rare complication of elective surgery with an incidence of 0.8 to 3.4 per 100,000 and a mortality rate of 1.8-12%; mortality may exceed 50% with misdiagnosis or delay in treatment. High index of suspicion is required when patients do not follow anticipated post-operative trajectory to initiate early treatment and supportive care.

Methods: Case report and review of the current literature.

Results: Rapid onset of hypotension, renal impairment, acute respiratory distress syndrome and a generalized macular rash across the chest and abdomen were observed 24 hours following elective total thyroidectomy. The patient returned to the operating room the evening of post-operative day one where a punctate tracheal injury was observed and wound cultures obtained, the final isolate being streptococcus pyogenes. This was successfully managed with early washout of the operative field, aggressive volume resuscitation, broad spectrum antibiotics with protein synthesis inhibition, and hemodynamic support with four vasopressors including Angiotensin-2 for refractory toxic shock syndrome.

Conclusion: High index of suspicion for TSS as the cause of refractory shock is essential to prevent high rates of mortality. Early re-exploration and source control are essential; the addition of broad-spectrum antibiotics should include protein synthesis inhibition. Angiotensin-2 for refractory shock may be useful in decreasing vasopressor requirements and improve mortality in severe septic shock.