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Abstract: TH-PO125

A Case of Streptococcal Toxic Shock Syndrome With Acute Renal Failure

Session Information

  • AKI: Mechanisms - I
    November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
    Abstract Time: 10:00 AM - 12:00 PM

Category: Acute Kidney Injury

  • 103 AKI: Mechanisms

Author

  • Tolani, Renuka, Palmetto General Hospital, Hialeah, Florida, United States
Introduction

Elderly patients with skin lesions and risk factors such as diabetes, can develop streptococcal toxic shock syndrome (STSS) with multiorgan involvement. Certain patients present with acute kidney injury (AKI), and later progress to renal failure requiring renal replacement therapy.

Case Description

Patient is an 86 year old male with past medical history of CKD stage 3b and diabetes (on Ozempic and insulin) who presents to the ED for weakness, chills, and fever after injuring his right arm on a car door the week prior. Physical exam was significant for tenderness and diffuse bullae, with sharp margin of erythema and desquamation in the right upper extremity. Patient was in septic shock with increasing lactic acidosis. Multiple pressors, IV fluids, and broad spectrum antibiotics were administered. Patient became tachypneic and required intubation. Initial labs were significant for leukocytosis of 15 with left shift, bicarb 20, anion gap 13, lactic acid 5.9, and creatinine 2.6 with GFR 23. ABG on 3 L NC showed metabolic acidosis with pH 7.131, pCo2 25, bicarb 8, paO2 98. Repeat labs showed bicarb level dropped from 20 to 9, with anion gap of 22 and lactic acid 17. Ph decreased to 7.057. Cr was 1.6 and GFR was 41 on labs the year prior, AKI on CKD stage 3b. Transaminitis more than 2 times the upper limit of normal also developed. Glucose was 200 without ketones or glucose noted in urine. A foley catheter was placed. Urgent exploratory surgery and biopsy were done. The patient grew strep pyogenes in both blood and wound cultures. Pathology report showed extensive coagulative necrosis with cocci like bacteria, without evidence of necrotizing fasciitis. Despite administration of bicarb drip and pushes, the patient’s acidosis did not improve. The patient had less than 500 ccs of urine production in 24 hours, and there was an increase of potassium to 6.3 from 4.6. The creatinine also increased to 4.3 from 2.6. Decision was made to begin Continuous Renal Replacement Therapy (CRRT). Urinalysis was negative for leukocyte esterase or nitrite, but showed WBC > 50 and RBC > 20. His family was offered the choice of right upper extremity amputation, but opted for comfort care.

Discussion

Clinicians should recognize the life-threatening process involved in STSS. Hypotension and toxin-induced hemolysis with myoglobinuria and hemoglobinuria, may contribute to acute renal failure and ATN for which CRRT plays a major role.