Correspondence

Case 28-2002: A Traveler with a Rapidly Progressive Soft-Tissue Infection

N Engl J Med 2003; 348:176-177January 9, 2003

Article

To the Editor:

There was no mention of human immune globulin therapy in the discussion of the patient who died from group A streptococcal toxic shock syndrome and necrotizing fasciitis (Case 28-2002) (Sept. 12 issue).1 Yet timely immune globulin therapy might have averted her death. Although no randomized trial of immune globulin therapy for toxic shock syndrome has been performed (or is likely to be performed), observational data and biologic plausibility support its use as a form of passive immunotherapy against the streptococcal superantigens, particularly in critical cases.2-4

James R. Johnson, M.D.
Veterans Affairs Medical Center, Minneapolis, MN 55417
johns007@umn.edu

4 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 28-2002). N Engl J Med 2002;347:831-837
   Full Text | Web of Science | Medline

2. 2

   Schlievert PM. Use of intravenous immunoglobulin in the treatment of staphylococcal and streptococcal toxic shock syndromes and related illnesses. J Allergy Clin Immunol 2001;108:Suppl:S107-S110
   CrossRef | Web of Science | Medline

3. 3

   Baracco GJ, Bisno AL. Therapeutic approaches to streptococcal toxic shock syndrome. Curr Infect Dis Rep 1999;1:230-237
   CrossRef | Medline

4. 4

   Kaul R, McGeer A, Norrby-Teglund A, et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome -- a comparative observational study. Clin Infect Dis 1999;28:800-807
   CrossRef | Web of Science | Medline

Author/Editor Response

The patient did receive adjunctive immune globulin therapy in addition to antibiotics for streptococcal toxic shock syndrome. As Dr. Johnson correctly notes, immune globulin therapy for streptococcal toxic shock syndrome has never been studied in a randomized trial. Nevertheless, in this case, we chose to use intravenous immune globulin, for the reason he outlines, in addition to antibiotic therapy and aggressive surgical débridement. Despite all these measures, the patient did not have a response. The mortality rate associated with streptococcal toxic shock syndrome remains high,1 and new treatments are clearly needed.

Rajesh Gandhi, M.D.
Massachusetts General Hospital, Boston, MA 02114
rgandhi@partners.org

1 References

1. 1

   Stevens DL. Streptococcal toxic shock syndrome associated with necrotizing fasciitis. Annu Rev Med 2000;51:271-288
   CrossRef | Web of Science | Medline