Severe puerperal group A streptococcal infection causing toxic shock-like syndrome

History and clinical findings: A previously healthy 32-year-old woman was admitted with shock symptoms 5 days after an uneventful home delivery. She developed a fever up to 39.5 degrees C during the days after delivery with sore throat, diarrhoea and muscle aches in all limbs. On physical examination there were swellings of the arms and lower legs as well as macular and vesicular erythrodermia, especially of the trunk. Investigations: Abnormal laboratory findings were thrombocytopenia (20000/mu l), increased serum concentrations of fibrin breakdown products (102 mg/dl) and of C-reactive protein (> 200 mg/dl), increased creatinekinase (5700 U/l), transaminases (COT 220 U/l, GPT 52 U/l), creatinine (2.0 mg/dl) and urea (114 mg/dl). Streptococcus pyogenes was grown on blood culture and from vaginal smear. Sonography, echocardiography and radiological examinations failed to demonstrate a septic focus. Treatment and course: Mechanical ventilation was required for 7 days because of respiratory failure and shock symptoms (toxic shock-like syndrome, TSLS). Penicillin G and tobramycin were given after the bacteriological diagnosis. Severe consumption coagulopathy was successfully treated with antithrombin III and platelet concentrates. After extubation she was found to have a flaccid tetraparesis, especially of the right and of the legs, due to soft-tissue necrosis and damage to peripheral nerves. An embolic occlusion of the right brachial artery 4 weeks after onset of the disease required upper-arm amputation. Conclusion: One of the decisive factors for the prognosis of TSLS is early antibiotic treatment. The prodromal symptoms in this case underline the necessity of early recognition and treatment to prevent a full-blown picture of the syndrome.