Streptococcal toxic shock syndrome associated with necrotizing fasciitis

Streptococcal toxic shock syndrome (strep TSS) with associated necrotizing fasciitis is a rapidly progressive process that kills 30-60% of patients in 72-96 h. Violaceous bullae, hypotension, fever, and evidence of organ fail ure are late clinical manifestations. Thus, the challenge to clinicians is to make an early diagnosis and to intervene with aggressive fluid replaceme nt, emergent surgical debridement, and general supportive measures. Superan tigens such as pyrogenic exotoxin A interact with monocytes and T lymphocyt es in unique ways, resulting in T-cell proliferation and watershed producti on of monokines (e.g. tumor necrosis factor alpha, interleukin 1, interleuk in 6), and lymphokines (e.g. tumor necrosis factor beta, interleukin 2, and gamma-interferon). Penicillin, though efficacious in mild Streptococcus py ogenes infection, is less effective in severe infections because of its sho rt postantibiotic effect, inoculum effect, and reduced activity against sta tionary-phase organisms. Emerging treatments for strep TSS include clindamy cin and intravenous gamma-globulin.