Streptococcal toxic shock syndrome: a description of 14 cases from North Yorkshire, UK.

Objective: To analyze the clinical and laboratory features of patients diagnosed with streptococcal toxic shock syndrome (TSS) in North Yorkshire from 1986 to 1999.

Methods: Records of patients with features satisfying the published criteria for streptococcal TSS were reviewed from laboratory and clinical records made at the time and from the hospital case notes. Isolates of streptococci were analyzed for serotype and genes encoding for the production of streptococcal pyrogenic exotoxins.

Results: Fourteen patients satisfied the entry criteria. In one district, where the data were complete, the annual incidence of detected streptococcal TSS rose from 1.1 to 9.5 cases per million population in the 1990s. TSS was associated with various M serotypes of group A streptococci and various exotoxin genotypes. Two cases (14% of the series) were associated with severe group G streptococcal infection. The fatality rate was 64%, and the mode of time to death was 4 days. Local tissue necrosis occurred in 71% of cases, including necrotizing fasciitis, intrathoracic and intra-abdominal forms. Non-steroidal anti-inflammatory drugs (NSAIDs) had been taken around the time of onset of disease by 92% of the patients with TSS.

Conclusions: There has been a dramatic increase in the number of detected cases of streptococcal TSS over the 14 years since the first case was recognized here. There was a wide range of invasive forms of infection, a high fatality rate even in fit young adults, and a rapid course from onset to death. There was a high association of TSS with aggressive streptococcal infection producing local tissue necrosis.