Toxic shock syndrome caused by Streptococcus pyogenes

Four days after being bitten by an insect a 35-year-old woman without any serious underlying disease developed an extensive phlegmonous inflammation of the left eyelid which soon spread to the entire left half of her face. Streptococcus pyogenes serotype M1, which produced the erythrogenic toxin A in vitro, was isolated from two blood cultures. The course of the illness was characterized by high fever, diarrhoea, vomiting, circulatory failure, consumption coagulopathy, abnormal renal functions and a generalized exanthem with desquamation of the skin, exhibiting the full-blown picture of a toxic shock syndrome caused by S. pyogenes. She eventually recovered completely under intensive care involving administration of catecholamines, fresh frozen plasma and antithrombin III substitution, as well as antibiotic treatment with clindamycin (600 mg three times daily), ampicillin/sulbactam (4 g three times daily)--after 3 days replaced by imipenem (0.5 g four times daily)--and gentamycin (80 mg three times daily) for two weeks. Extensive necroses later required plastic surgery to the left eyelid, cheek and temporal region.