Congestive cardiomyopathy after streptococcal toxic shocklike syndrome

Excerpt

Sir: We report the case of a 35-year-old otherwise healthy woman who developed toxic shocklike syndrome (TSLS) with multiple organ failure several hours after two intra-articular injections of a corticosteroid in her right shoulder due to pain. The infection spread along her right shoulder, right upper extremity, and right lateral chest wall up to the iliac crest and induced extensive necrosis. Isolation of β-hemolytic group A streptococci from blood and tissue confirmed the clinical diagnosis. Immediate surgical intervention, combined antibiotic treatment (penicillin, clindamycin and fosfomycin), and immunoglobulin administration were performed. Hyperbaric oxygen therapy is not available in our institution. Ischemic acral necrosis resulted in the loss of all fingers of her right hand, distal phalanges of her left hand and the distal part of both legs including all ossa metatarsalia. Hemofiltration bridged acute renal failure, acute respiratory distress syndrome, and pneumonia required ventilatory support. The TSLS-related hemodynamic instability and low cardiac index of 1.6 l min⁻¹ m⁻², with blood lactate levels up to 204 mg/dl at admission required high doses of inotropic agents (milrinone 40 µg/min, levosimendane 8 µg/min), catecholamines (epinephrine 100 µg/min, norepinephrine 30 µg/min), and vasopressin-arginine (4 U/h) for 6 days, cardiac index increased to 2.0 l min⁻¹ m⁻². Daily electrocardiography revealed pathological ischemic findings in the anteroseptal and lateral area. Troponin I levels peaked at 750 U/l on day 3. Transesophageal echocardiography carried out 1 day after admission displayed biventricular dilation (ELVD 63 mm) and global reduced contractility (left ventricular ejection fraction 20–25%) due to systolic dysfunction and septal, anteroseptal and inferior wall movement disturbances. Left ventricular ejection fraction remained unchanged during her hospital stay and was still the same at cardiological follow-up 1 year later. Additional drug therapy included an angiotensine converting enzyme inhibitor, diuretics, a β-blocker, and anticoagulation after circulatory stabilization. …