Atypical Presentation of Group A Streptococcal Puerperal Sepsis & Toxic Shock Syndrome: A Case Report

 Authors: Shahana Abdu1 Frances Hodge2 Mitra Kanagaraj3 John ChittilappillyJoy4

 ST7 O&G1, Consultant O&G2,Foundation doctor3 Princess of Wales CoityRoad, Bridgend CF31 1RQ, Wales, UK. Consultant Radiologist 4 Royal Glamorgan Hospital, Llantrisant, CF72 8XR, Wales, UK

 

Introduction

 

• Sepsis accounts for 11% of maternal deaths worldwide.1

 

• Maternal sepsis due to Group A beta-haemolytic streptococci (GAS) are particularly recognized for their high virulence, nonspecific presentation and rapid progression to invasive GAS (iGAS), life-threatening infections.2

 

• Pregnant women face a 20-fold greater risk of developing iGASinfections compared to non-pregnant women and this risk increases up to 80-fold within the first 28 days postpartum.2

 

 Case summary

 

• A low riskyoung woman, para 1, presented on postpartum day 6 following a midwifery-led vaginal delivery with sudden-onset swelling of both upper and lower limbs on the same side, without typical symptoms of endometritis or genital tract infection.

 

• Stable on admission, except for mild fever of 37.7°C. Examination revealed mildly tender but significant swelling in both limbs with no discolouration, unremarkable pelvis-DVT was suspected but ruled out by Doppler USG.

 

• Laboratory tests -elevated inflammatory markers and slightly deranged electrolytes and liver function tests.

 

• A CT abdomen and pelvis-possible endometritis, but no evidence of retained products of conception (RPOC).

 

• Commenced on the Sepsis Six pathway, including IV antibiotics Cefuroxime and Metronidazole and vigorous intravenous fluid therapy.

 

• However, over a few hours, developed septic shock followed by a full-blown iGASinfection such as streptococcal toxic shock syndrome (STSS), necrotizing fasciitis (large skin blisters and discoloration), multiorgan dysfunction, and disseminated intravascular coagulation (DIC) in 1-2 days.

 

• Blood and genital cultures confirmed invasive Group A Streptococcus (GAS, type emm77). Notified infection prevention team and neonatology team.

 

• Antibiotics were escalated to Meropenem and Clindamycin, and required intubation, inotropic support, IV immunoglobulin therapy, albumin, and blood products.

 

• Multidisciplinary input including Orthopaedics, General Surgery, and Plastic Surgery.

 

• Removal of source infection by fasciotomy, extensive wound debridement, and uterine evacuation (although no RPOC was identified).

 

• Gradually improved and transferred to a tertiary centre for multiple reconstructive plastic surgeries.

 

• Discharged with extensive and prolonged physiotherapy and occupational therapy plans, along with support from the emotional support team after 8 weeks of hospital stay.

 

Discussion

 

• GAS is a Gram-positive coccus that spreads via close contact and causes mild to deadly infections.2

 

• Relatively uncommon in the UK (annual incidence of 2–3 cases per 100,000 individuals), but a recent resurgence has been reported.3

 

• iGASis extremely virulent, with a maternal mortality rate of over 40% if complicated by septic shock.3

 

• Atypical symptoms, such as limb swelling, severe limb pain, malaise, and serosanguinous or watery lochia with no offensive odour are common and delay diagnosis.2

 

• iGASleads to rapid deterioration to endometritis, necrotizing fasciitis, STSS, septic shock, multiorgan failure, and death.

 

• Heightened vigilance, early recognition and intervention are the vital measures.2

 

• Early interventions -prompt initiation of the Sepsis Six bundle: fluid resuscitation, blood cultures, and administration of broad-spectrum intravenous antibiotics (as per the local guideline) within one hour, senior escalation and multidisciplinary team input.

 

• Intravenous immunoglobulin acts synergistically with clindamycin to neutralize exotoxins in severe or unresponsive cases.

 

• Identification and control of the infection source is key to limiting spread, including evacuation of RPOC, abscess drainage, wound debridement, or hysterectomy in case of uterine or adnexal necrosis.2

 

• In this case, although the initial differential diagnosis considered deep vein thrombosis, a high index of suspicion and prompt, aggressive intervention, including surgical source control, ultimately saved this woman’s life and prevented an amputation; even then, the morbidity from the extensive tissue loss was profound and devastating.

 

Conclusion

 

• This case highlights the critical need for clinical awareness and rapid diagnosis of iGASinfections. Enhanced training and diagnostic protocols are essential to improving patient outcomes.

 

• Raising awareness in pregnant women and health care workers about GAS infection and hygiene is vital.

 

• Future practice should prioritize rapid diagnostic tools and protocols to improve patient outcomes.

 

References

 

1. L. Say, et al., “Global Causes of Maternal Death: A WHO Systematic Analysis,” Lancet Global Health 2 (2014): e327

 

2. RCOG, -Identification and Management of Maternal Sepsis During and Following Pregnancy, Green Top Guideline No.64. Available in https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.18009 December 2024

 

3. Androulla Efstratiou,andTheresa Lamagni, Epidemiology of Streptococcus pyogenes-2020. Available in https://www.ncbi.nlm.nih.gov/books/NBK587100-National Library of Medicine

 

Contact: shahanaabdu88@gmail.com