Therapeutic Approaches to Streptococcal Toxic Shock Syndrome

The streptococcal toxic shock syndrome (STSS) is a severe, life-threatening condition characterized by hypotension and multiorgan system dysfunction associated with infection by the group A Streptococcus (GAS) or rarely by streptococci of other Lancefield serogroups. It is associated with a soft tissue infection, such as necrotizing fasciitis, in about half of the cases; the remainder are secondary to a variety of other invasive and noninvasive GAS infections. Although the pathophysiology of STSS is not yet fully understood, there are compelling reasons to believe that the syndrome results at least in part from the action of the streptococcal pyrogenic exotoxins, which act as superantigens. Patients with STSS should be admitted to an intensive care unit for support of cardiovascular, respiratory, and renal function as required. In experimental models of overwhelming GAS infection, clindamycin has greater efficacy than penicillin, and therapy with this agent is recommended. Penicillin, to which GAS are uniformly susceptible, may be used in addition to clindamycin. Limited clinical experience, most of which is anecdotal, suggests marked improvement in some STSS patients after administration of intravenous immunoglobulin. Even in the absence of conclusive data, the potential benefits of intravenous immunoglobulin in this highly lethal disease make its use reasonable in life-threatening cases. Other experimental approaches are also discussed, such as the use of anti-tumor necrosis factor monoclonal antibodies and plasmapheresis.