A 28-year-old woman is admitted to the ICU with septic shock due to a soft-tissue infection. Three days prior to admission, she fell while riding her bicycle and sustained lacerations to her legs which she self-treated. Within the ICU, she undergoes fluid resuscitation, receives vasopressor support and broad-spectrum antibiotics, and is taken for surgical debridement. Tissue and blood cultures grow Streptococcus pyogenes and antibiotics are narrowed to penicillin and clindamycin. Two days later, she remains febrile, and vasopressor dependent, has a generalized rash, develops acute kidney injury requiring renal replacement therapy as well as elevated transaminases and jaundice. Sensitivity testing shows no antimicrobial resistance and no further organisms.
Which of the following interventions is MOST likely to be beneficial for treatment of this patient?
A. Intravenous immunoglobulin (IVIG) administered for 3 daysCorrect Answer: A
Group A Streptococcus (S. pyogenes) can produce exotoxins and superantigens that lead to streptococcal toxic shock syndrome characterized by rapidly progressive soft-tissue destruction, shock, and multiple organ failure. Although there is mixed evidence, several studies show benefit of IVIG in cases of streptococcal toxic shock syndrome. IVIG may raise antibody levels by passive immunity in the setting of overwhelming infection. It may contribute neutralizing antibodies against streptococcal exotoxins—however these may differ by specific manufacturer preparations. Hyperbaric oxygen has been studied to varying effect in necrotizing infection, but there is no indication that it would have any direct benefit in this patient. Clinical trials have not demonstrated a benefit of anti-TNF antibody administration in patients with septic shock. There is no role for changing antibiotic regimen in this patient with pansusceptible S. pyogenes, and no polymicrobial infection.
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