[High-dose immunoglobulin--life-saving in invasive group A streptococcal infection. Report of eleven cases with only one fatality]
[Article in Swedish] Lakartidningen. 2004 Aug 26;101(35):2642-4.
Arnholm B, Lundqvist A, Stromberg A.
Infektionskliniken Sodra Alvsborgs sjukhus, Boras.
Invasive group A streptococcal infection is an uncommon but severe disease. Bloodcultures usually yield growth of Streptococcus pyogenes and the bacteria may also be isolated from sterile sites e.g. muscle or pleura.
The most serious manifestation is Streptococcal Toxic Shock Syndrome (STSS) with or without necrotizing fasciitis (NF). This condition may occur in about a fifth of the cases with a very high case-fatality rate. Preclinical data and case reports suggest that the fatality rate can be reduced by treatment of high-dose intravenous immunoglobulin. A European placebo-controlled clinical trial with immunoglobulin has been conducted but was prematurely terminated due to difficulties in patient recruitment. In our clinic we have during the last 3.5 years seen 41 patients with invasive group A streptococcal infection and 11 of these have received high-dose immunoglobulin. The indication for that treatment has been hypotension and multiorgan failure. All 11 patients but one fullfilled the criteria for STSS and 5 had NF. Most of the patients were treated with a single dose intravenous infusion of 50 g immunoglobulin. All patients were treated with both benzylpenicillin and clindamycin. Ten patients were fully recovered--case-fatality rate 9 percent. We suggest that patients with invasive group A streptococcal infections who develop STSS with or without NF should be treated with high-dose intravenous immunoglobulin.