IBC Oxford University Poster Abstract 26 - Silent threat: unmasking streptococcal toxic shock syndrome post-surgery
Authors: Oliveira A , Resende F , Santos-Sousa H , de Sousa J P Vieira , Caires F , Gonçalves F , Pinho A , Preto J , Carneiro S , da Costa E Lima 
Published: February 2025

Abstract

Introduction
Streptococcal toxic shock syndrome (STSS) is a severe septic shock syndrome caused by infection with toxin-producing group A streptococci (GAS). Although rare, STSS can present as primary peritonitis in otherwise healthy individuals. Most reported cases of STSS have been associated with pre-existing conditions or procedures such as childbirth, skin infections, or surgeries. The symptoms of STSS are often non-specific, resembling flu-like symptoms, but can rapidly progress to life-threatening toxic shock within hours. To date, only a few cases have been reported, predominantly in women of reproductive age.

Methods
Clinical case of a 50-year-old woman with a history of obesity and psoriatic arthritis, treated with immunosuppressants and corticosteroids, who underwent an uncomplicated sleeve gastrectomy and was discharged after two days. However, on the fifth postoperative day, she developed severe abdominal pain and odynophagia and was admited to the emergency department with multiorgan dysfunction.

Results
An abdominopelvic CT scan with oral contrast did not reveal any significant findings except for a suspected respiratory infection and a small amount of pelvic free fluid. It was decided to perform an exploratory laparoscopy, with a normal methylene blue test. A conversion to laparotomy was needed due to the patient's instability and the need to explore the abdominal cavity and all the intestinal bowl. This procedure revealed peritonitis with no apparent focus. The patient spent four months in intensive care due to streptococcal toxic shock secondary to peritonitis caused by Streptococcus pyogenes. Her hospital stay was marked by numerous infectious complications, including urinary and respiratory infections, bacteremia, fungemia, and bilateral below-knee amputation due to extremity necrosis, ultimately resulting in her death.

Discussion
Diagnosing GAS primary or secondary peritonitis can be challenging. It is crucial to determine whether the sepsis is due to a surgical cause, such as perforation, ischemia, or bowel obstruction. Epidemiological studies have shown an increase in the incidence and severity of GAS infections. The literature identifies female gender, immunosuppression, and preceding varicella infection as risk factors for developing primary S. pyogenes peritonitis. With a fatality rate of 40% or higher, STSS remains a critical condition, with no reported cases following bariatric surgery. GAS infections are well-known for causing pharyngitis, which likely occurred in this case. The significance of drainage in reducing bacterial load has been emphasized in STSS. Consequently, for patients with extensive intra-peritoneal free fluid observed on CT scans, or for those whose condition worsens despite antibiotic treatment, peritoneal lavage should be performed. The key challenge for surgeons is to recognize the potential for this diagnosis, emphasizing the importance of clinical vigilance, early detection, and prompt treatment in suspected cases.