Use of Double Dose Intravenous Immunoglobulin Therapy in the Treatment of Streptococcal Toxic Shock Syndrome

Streptococcal toxic shock syndrome (STSS) is a life-threatening condition with increasing incidence and high mortality worldwide. It is characterised by hypotension and multiorgan failure, resultant of invasive group A Streptococcus (GAS) infections. Intravenous immunoglobulin (IVIG) has been proposed as an adjunctive therapy that reduces mortality in patients with STSS, and is thought to exert its effects by neutralising streptococcal superantigens and exotoxins to modulate the host immune response. Currently, there is a paucity of knowledge about the efficacy of repeated dosing if patients remain unstable after the first dose of IVIG. In this report, we describe the case of a woman in her 60s with STSS and meningoencephalitis, who demonstrated an improvement in haemodynamic status after the first dose of IVIG, but subsequently had rebound of hypotension and high vasopressor requirements, which resolved after a second dose of IVIG. This case highlights the potential need for repeated dosing of IVIG in STSS, in situations where an initial improvement in haemodynamic status is followed by deterioration.