Group A Streptococcus (GAS) or Streptococcus pyogenes is an aerobic gram-positive coccus that causes a multitude of infections that range in severity. GAS most commonly infects the soft tissues, which results in infections such as cellulitis, erysipelas, necrotizing fasciitis and myositis. These deep soft tissue infections are also the most common source of GAS bacteremia. Other common infections caused by GAS include pharyngitis, rheumatic fever and glomerulonephritis.1 The lower respiratory tract is an uncommon site for GAS infection and it is the least common source of GAS bacteremia; however, in adults with GAS pneumonia, the incidence of bacteremia is 80 percent.2 Patients with a severe GAS infection can develop streptococcal toxic shock syndrome, which consists of GAS bacteremia in conjunction with shock and organ failure. Here we present a case of severe GAS pneumonia complicated by toxic shock syndrome and purpura fulminans, a rare complication of disseminated GAS infection.

Case Presentation

A 57-year-old male with a history of gastric adenocarcinoma status post partial gastrectomy presented with a two-day history of shortness of breath and chest tightness. He denied any associated fevers, cough, sputum production, pharyngitis, diarrhea or dysuria. In the emergency room, he was afebrile (although he had been taking acetaminophenoxycodone tablets every 4 to 6 hours for his chest pain) with a heart rate of 123 bpm, blood pressure 78/49 mmHg, respiratory rate 21-27 bpm, and pulse oximetry of 94% on a non-rebreather. Physical exam revealed right upper lobe rales, as well as egophony and sinus tachycardia. There was no evidence of pharyngeal erythema, exudates, or ulcers. Pertinent lab work on admission included a creatinine of 2.3 mg/dL and a lactate of 9.0 mmol/L. Computed tomography (CT) of his chest was consistent with pneumonia in the right upper lobe with patchy areas of consolidation in the right middle and lower lobes. The patient received ceftriaxone, azithromycin and five liters of normal saline. He was admitted to the medical intensive care unit (MICU) for severe sepsis secondary to communityacquired pneumonia.