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"Shock, Septic"[Mesh]) AND "Staphylococcus aureus" [Mesh]) AND "Streptococcus pyogenes"[Mesh] and "Staphylococcal Scalded Skin Syndrome"[Mesh]) AND "Shock, Septic"[Mesh], with no time restriction).</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 54-year-old woman with no past history of interest who presented to the emergency department with a 1-week history of fever, hypotension and general malaise associated with skin lesions. She had erythema with epidermal peeling affecting 30% of the body surface and a positive Nikolsky's sign on all 4 limbs. The trunk showed erythema without epidermal detachment and the mucous membranes were intact. Laboratory tests showed a procalcitonin level of 124 ng/ml, hypoglycaemia, elevated creatinine and metabolic acidosis with lactic acid of 14 mmol/l. The patient was admitted to the intensive care unit with suspected SSSS associated with probable <span class="elsevierStyleItalic">septic shock</span> and empirical antibiotic therapy with vancomycin and clindamycin was started.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Blood cultures, cultures of pharyngeal, perineal, nasal and axillary exudates and a skin biopsy from the left arm were obtained.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> sensitive to oxacillin was isolated from the pharyngeal exudate. Pathology showed intraepidermal neutrophilic abscesses, subcorneal cleavage plane and superficial perivascular dermatitis with oedema in papillary dermis.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus pyogenes</span> was isolated from blood cultures, which, associated with the data on multi-organ failure, was suggestive of STSS.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient required vasoactive drugs, invasive mechanical ventilation and bicarbonate perfusion for metabolic acidosis. Despite the measures taken, the clinical condition worsened, with an increase in the area of skin affected, worsening of the laboratory parameters and the appearance of oedema and retiform purpura on all four limbs, more evident on the left arm. Traumatology made a clinical diagnosis of necrotising fasciitis, with surgical exploration and fasciotomy of the 4 limbs, showing exudate like “meat-washing water" in the fascial compartments of the arms and legs. The diagnosis was confirmed by microbiological culture. Subsequently, transhumeral amputation of the right arm and bilateral supracondylar amputations were performed due to lack of distal tissue viability caused by ischaemia. This was followed by sepsis due to <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Candida</span>, as well as keratitis due to <span class="elsevierStyleItalic">P. aeruginosa</span>. Finally, after 15 days in hospital, the patient died.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Invasive streptococcal infection is defined as the presence of <span class="elsevierStyleItalic">S. pyogenes</span> in a sterile site. It is common in immunocompetent patients, requires a gateway to occur and has a high mortality rate. One third of cases are associated with STSS, defined as hypotension and evidence of multi-organ failure, including necrotising soft tissue infection. This syndrome is caused by the massive production of pro-inflammatory cytokines following indiscriminate stimulation by pyrogenic exotoxins from <span class="elsevierStyleItalic">S. pyogenes</span> on T-cell receptors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand, necrotising fasciitis due to <span class="elsevierStyleItalic">S. pyogenes</span> can be caused by a local harmful agent such as a wound or by haematogenous spread, and can exceptionally be multifocal, as in the case reported.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Diagnosis is clinical and should be suspected if there is disproportionate pain, oedema, erythema or signs of necrosis. Treatment should be early, with intravenous immunoglobulin, antibiotic therapy and emergency fasciotomy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case is particularly relevant as it is associated with an SSSS, as a gateway for invasive streptococcal infection. This syndrome consists of erythematous skin lesions with epidermal peeling and positive Nikolsky's sign, following infection with <span class="elsevierStyleItalic">S. aureus</span> and may present with systemic prodromes. It is caused by the production and passage into the bloodstream of the exfoliative toxin A or B of <span class="elsevierStyleItalic">S. aureus</span>, which acts as a serine protease of desmoglein-1, present in the desmosomes of the upper layers of the epidermis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is more common in children and is associated with immunosuppressive factors in adults. The differential diagnosis should mainly be made with Steven-Johnson syndrome, which commonly affects mucous membranes, in contrast to SSSS, and is usually an immune-mediated adverse drug reaction. Treatment consists of empirical antibiotic therapy including clindamycin, supportive care and skin dressings. The prognosis is good if there are no complications.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with the ethical requirements necessary for the preparation of the article, including the taking of informed consent where necessary.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">No public or private sector funding was received for the production of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nonspecific and specific immunological mitogenicity by group A streptococcal pyrogenic exotoxins" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.L. Barsumian" 1 => "P.M. Schlievert" 2 => "D.W. Watson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/iai.22.3.681-688.1978" "Revista" => array:7 [ "tituloSerie" => "Infect Immun" "fecha" => "1978" "volumen" => "22" "paginaInicial" => "681" "paginaFinal" => "688" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/365764" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0016508515011798" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "‘Synchronous’ multifocal necrotizing fasciitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "I. Tocco" 1 => "L. Lancerotto" 2 => "A. Pontini" 3 => "A. Voltan" 4 => "B. Azzena" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jemermed.2013.05.064" "Revista" => array:5 [ "tituloSerie" => "J Emerg Med" "fecha" => "2013" "volumen" => "45" "paginaInicial" => "e187" "paginaFinal" => "e191" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Split stories converge at desmoglein 1" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.J. Epstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/81306" "Revista" => array:6 [ "tituloSerie" => "Nat Med" "fecha" => "2000" "volumen" => "6" "paginaInicial" => "1213" "paginaFinal" => "1214" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11062527" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016200000012/v1_202406200625/S2387020624002146/v1_202406200625/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016200000012/v1_202406200625/S2387020624002146/v1_202406200625/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624002146?idApp=UINPBA00004N" ]
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Vol. 162. Issue 12.
Pages 615-616 (June 2024)
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Vol. 162. Issue 12.
Pages 615-616 (June 2024)
Letter to the Editor
Streptococcal toxic shock syndrome and multifocal necrotizing fasciitis secondary to staphylococcal scalded skin syndrome in the same patient
Síndrome del shock tóxico estreptocócico y fascitis necrosante multifocal secundarios a síndrome de la piel escaldada estafilocócica en un mismo paciente
José Pablo Serrano Serra
, José Francisco Orts Paco, José Navarro Pascual
Corresponding author
Servicio de Dermatología, HGU Reina Sofía, Murcia, Spain
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