Case Presentation:

A 35‐year‐old woman presented to the emergency room with nausea, vomiting and abdominal pain of 3 days duration. Her initial blood systolic blood pressure was 50. Her physical exam was normal other than a diffusely tender abdomen. Laboratory tests showed a WBC count of 6000/μL with 71% bands and platelets of 131. The INR and PTT were both elevated and were 1.32 and 39.1, respectively. Her creatinine was 2.9 and sodium was 128 mEq/L. Liver function tests, venous lactate level and urinalysis were normal. Chest x‐ray and abdominal sonograms were normal. A noncontrasl CT scan of the abdomen and pelvis revealed mild to moderate thickening of the wall of the ascending colon and increased density in the adjacent mesenteric fat. She was given fluid resuscitation and vasopressors to maintain an acceptable blood pressure. She underwent laparoscopic exploration of the abdomen. She had purulent exudates in the peritoneal space but an obvious cause was not found. The appendix was removed as a precaution. She was sent to the ICU and remained intubated. She was treated with broad‐spectrum antibiotics, multiple vasopressors and hydrocortisone. On postoperative day 2, rare group A streptococcus (GAS) grew from her purulent abdominal fluid. Her blood, urine, stool cultures were negative. She improved and was extubated on the fifth hospital day. She was discharged on hospital day 9 on a 2 week course of Augmentin.


This is a case of GAS toxic shock syndrome (TSS). Previously, TSS occurred more commonly with Staphylococcus aureus (SAJ infections. Currently, it is more commonly seen with invasive GAS infections. TSS occurs due to exotoxins produced by the bacteria that elicit a severe systemic inflammatory response by way of the T‐lymphocytes. An overt infection is not necessary to cause TSS with SA but is usually present with GAS TSS. Our case had no obvious portal of entry (although vaginal was our primary suspicion). GAS TSS is characterized by isolation of GAS from a normally sterile site, hypotension and 2 or more of the following: renal impairment, coagulopathy, liver abnormalities, ARDS, rash, and skin necrosis.


TSS, although rare, is a serious, life‐threatening condition. Hospitalists must be vigilant for the presence of TSS and know that it often occurs without an obvious site of infection.

Author Disclosure:

J. Strohecker, none; N. Fujita, none