Streptococcal Toxic Shock Syndrome Caused by a Streptococcus pyogenes emm22 Genotype with a CsrS Mutation: a Case Report

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A previously healthy 22-year-old woman was admitted to our hospital after an out-of-hospital cardiac arrest. Spontaneous circulation was restored prior to arrival at the hospital. However, the patient’s vital signs remained unstable. Vasopressors and hyperhydration therapy were administered. Computed tomography did not reveal a cause of the cardiac arrest. Antibiotics were initiated after obtaining blood culture samples. The patient was admitted to the intensive care unit (ICU). High-dose vasopressors and hyperhydration therapy were continued and fresh frozen plasma was transfused. Two hours after ICU admission, gram staining of a blood smear revealed the presence of Streptococcus, and the antibiotics were switched to penicillin G potassium and clindamycin, and immunoglobulins were administered. Extracorporeal membrane oxygenation was initiated 10 h after ICU admission owing to respiratory failure caused by fluid overload; however, the patient’s condition did not improve and she died 40 h after admission. Blood culture results confirmed the presence of Streptococcus pyogenes; the T and M serotypes were unclassifiable. The emm genotype was emm22. Sequencing revealed the presence of streptococcal pyrogenic toxin genes, speA and speB, whereas speC was absent. CsrS, CsrR, and Rgg amino acid sequencing revealed the presence of a CsrS mutation.