Introduction: Group A Streptococcal (GAS) toxic shock syndrome (TSS) is a rare but life-threatening condition characterized by rapid onset of shock and multiorgan failure due to streptococcal superantigens. Though often associated with pharyngitis, skin trauma, or surgical wounds, it can present in healthy individuals without a clear source. Prompt diagnosis, antimicrobial therapy, and supportive care are critical to improving outcomes. Description: A 60-year-old woman with no past medical history presented with 1 week of progressive redness, swelling, and pain of the right upper extremity, flank, and abdomen after returning from travel to Europe. On arrival, she was febrile (Tmax 103°F), hypotensive (BP 94/72), and tachycardic. Labs revealed WBC 23.6, lactate 5.6 mmol/L, anion gap 20, TBili 2.2, and alkaline phosphatase 261. CT imaging showed diffuse cellulitis involving the right shoulder, breast, axilla, upper arm, and lateral abdomen, without subcutaneous air or drainable fluid collections. She was started on broad-spectrum antibiotics and taken urgently to the OR. Incision and drainage of the right upper extremity and chest wall revealed marked edema down to fascia, but no purulence or necrosis. Blood cultures grew GAS, and a diagnosis of streptococcal TSS was made. She was intubated, placed on vasopressors, and transitioned to penicillin, clindamycin, and three doses of IVIG. Despite resolution of bacteremia and surgical exploration, she remained hypotensive for several days, requiring high-dose norepinephrine. Repeat imaging, including echocardiogram and CT maxillofacial, failed to identify a primary source. Over time, with fluids, albumin, and blood products, her vitals stabilized and vasopressors were weaned. Persistent arm swelling prompted repeat CT, which showed worsening edema and myositis without abscess. She was transitioned to oral amoxicillin with clinical improvement and was discharged home. Discussion: This case highlights the diagnostic and therapeutic challenges of GAS TSS without an identifiable nidus. The absence of necrotic tissue or abscess can delay diagnosis, underscoring the importance of clinical suspicion. Clindamycin and IVIG play key roles in toxin suppression. Aggressive supportive care and multidisciplinary coordination are essential for survival.
Cascio et al. (Sun,) studied this question.