gms | German Medical Science

Severe group A streptococcal toxic shock syndrome (STSS) has generally a poor outcome. Patients present a life-threatening toxic shock syndrome within hours resulting from a harmful injury or infection with beta-hemolytic streptococci. The fast progression will lead to the death unless prompt supportive and aggressive treatment. There are only a few cases published in literature and mostly only case reports.

We report 3 cases of previously immune-competent, 41- to 76-year-old, male patients. The hospitalisation took place during 2012 and 2014. The referral to our acute interdisciplinary center was made for further treatment of suspected necrotizing fasciitis. Diagnosis included a combination of laboratory, imaging modalities and histological analysis. The patients were healthy and did not suffer any chronical condition. Initially started antibiotic therapy was in the course matched to the infectiological results. All surgical intervention was led by our plastic-surgeon-team.

All patients had to have an intensive care support because of their serious condition with mechanical ventilation and monitoring. The average stay at the intensive care unit was 20 days, the hospital stay took on average 57 days. The improvement of the physical condition was made by rapidly initiated antibiotic treatment and immediate aggressive surgery. CT scan was initiated with two patients who had an unknown focus of infection.

Patient 1 suffered from a peripharyngeal abscess which was shown on the CT scan. He developed a severe general state of health and a progressive soft tissue destruction due to the peripharyngeal abscess. Involving an ENT doctor was needed for resection of the palatine tonsils and the abscess cavity. Furthermore this patient had to undergo partial amputation of the lisfranc-joint at both lower legs. For preventing functional movement we performed a Pirogoff-amputation on one forefoot with the assistance of orthopedic specialists from the university hospital Balgrist/Zurich. On the other forefoot we performed a free Gracilis-flap. Figure 1 [Fig. 1], Figure 2 [Fig. 2], Figure 3 [Fig. 3], Figure 4 [Fig. 4], Figure 5 [Fig. 5] and Figure 6 [Fig. 6] show the clinical findings pre-/peri and postoperative of patient 1.

The other patient (Patient 2) with unknown focus showed in the course a portal of entry on the hand. He suffered a severe hyperactive delirium due to a chronic alcohol abuse. Therefore we could not obtain a medical history.

The third patient (Patient 3) got a known sharp cut on the palm by a metal plate. He suffered a necrotizing fasciitis with a septical state of health within 24 hours after injury. All patients had to undergo on average 8 surgical interventions with debridement on the particular extremities. Successful outcome was possible provided by a multidisciplinary, intensive and continuous both conservative and surgical therapy in close collaboration [1].

STSS is a rare described condition and to our knowledge no evidence based medical guideline is known. The survival of the life-threatened bacteriosis is only warranted by rapid therapy of an experienced team by plastic surgeons, infectiologists, intensive-care physicians and other surgical discipline. As soon as the critical condition passed the team has to be extended by nutrition counseling, psychiatrists, physio- and occupational therapists. Together with this extensive collaboration the best outcome will be required. Long stay at the hospital with multiple surgeries and a subsequent long-term rehabilitation provide a sufficient recovery and a successful therapy.

The authors declare that they have no competing interests.

At the 46^th meeting of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) the corresponding abstract [2] was awarded “Best Abstract”. The society highlighted the best abstract submissions with this award in 2015. The publication of the extended abstract in GMS German Plastic, Reconstructive and Aesthetic Surgery – Burn and Hand Surgery was sponsored by “Amryt Pharma”.