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Streptococcus pyogenes
Recensement CHU
bull 2016 2017
bull Inf ORL 11 6
bull Tissus mous 17 16
bull Autres 4 4
bull Total 32 26
Infections des tissus mous
bull Plaie infecteacutee 6 + 4
bull Erysipegravele 3 + 0
bull Cellulite 3 + 5
bull Fasciite 5 + 7
Autres infections
bull 1 bronchopneumonie
bull 1 infection drsquoascite avec bacteacuterieacutemie
bull 2 bacteacuterieacutemies post amygdalectomie
bull 2 bacteacuterieacutemies nosocomiales
Fasciite neacutecrosante
bull Deacutecrite par Meleney en 1924hemolytic streptococcal gangreneneacutecrose extensive des tissus mous allant
jusqursquoau fascia et aux muscleseacutevoluant sur 5 agrave 10 joursmortaliteacute de 20 (sans ATB sans USI)
Facteurs et circonstances favorisant
bull Revue de 1988 pour les bacteacuterieacutemiesenfants et vieillards brucircleacutes Insuffisants
reacutenaux cancer immunosupprimeacutes
bull Depuis alcool et diabegravete souvent aucun anteacuteceacutedent notable
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Recensement CHU
bull 2016 2017
bull Inf ORL 11 6
bull Tissus mous 17 16
bull Autres 4 4
bull Total 32 26
Infections des tissus mous
bull Plaie infecteacutee 6 + 4
bull Erysipegravele 3 + 0
bull Cellulite 3 + 5
bull Fasciite 5 + 7
Autres infections
bull 1 bronchopneumonie
bull 1 infection drsquoascite avec bacteacuterieacutemie
bull 2 bacteacuterieacutemies post amygdalectomie
bull 2 bacteacuterieacutemies nosocomiales
Fasciite neacutecrosante
bull Deacutecrite par Meleney en 1924hemolytic streptococcal gangreneneacutecrose extensive des tissus mous allant
jusqursquoau fascia et aux muscleseacutevoluant sur 5 agrave 10 joursmortaliteacute de 20 (sans ATB sans USI)
Facteurs et circonstances favorisant
bull Revue de 1988 pour les bacteacuterieacutemiesenfants et vieillards brucircleacutes Insuffisants
reacutenaux cancer immunosupprimeacutes
bull Depuis alcool et diabegravete souvent aucun anteacuteceacutedent notable
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Infections des tissus mous
bull Plaie infecteacutee 6 + 4
bull Erysipegravele 3 + 0
bull Cellulite 3 + 5
bull Fasciite 5 + 7
Autres infections
bull 1 bronchopneumonie
bull 1 infection drsquoascite avec bacteacuterieacutemie
bull 2 bacteacuterieacutemies post amygdalectomie
bull 2 bacteacuterieacutemies nosocomiales
Fasciite neacutecrosante
bull Deacutecrite par Meleney en 1924hemolytic streptococcal gangreneneacutecrose extensive des tissus mous allant
jusqursquoau fascia et aux muscleseacutevoluant sur 5 agrave 10 joursmortaliteacute de 20 (sans ATB sans USI)
Facteurs et circonstances favorisant
bull Revue de 1988 pour les bacteacuterieacutemiesenfants et vieillards brucircleacutes Insuffisants
reacutenaux cancer immunosupprimeacutes
bull Depuis alcool et diabegravete souvent aucun anteacuteceacutedent notable
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Autres infections
bull 1 bronchopneumonie
bull 1 infection drsquoascite avec bacteacuterieacutemie
bull 2 bacteacuterieacutemies post amygdalectomie
bull 2 bacteacuterieacutemies nosocomiales
Fasciite neacutecrosante
bull Deacutecrite par Meleney en 1924hemolytic streptococcal gangreneneacutecrose extensive des tissus mous allant
jusqursquoau fascia et aux muscleseacutevoluant sur 5 agrave 10 joursmortaliteacute de 20 (sans ATB sans USI)
Facteurs et circonstances favorisant
bull Revue de 1988 pour les bacteacuterieacutemiesenfants et vieillards brucircleacutes Insuffisants
reacutenaux cancer immunosupprimeacutes
bull Depuis alcool et diabegravete souvent aucun anteacuteceacutedent notable
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Fasciite neacutecrosante
bull Deacutecrite par Meleney en 1924hemolytic streptococcal gangreneneacutecrose extensive des tissus mous allant
jusqursquoau fascia et aux muscleseacutevoluant sur 5 agrave 10 joursmortaliteacute de 20 (sans ATB sans USI)
Facteurs et circonstances favorisant
bull Revue de 1988 pour les bacteacuterieacutemiesenfants et vieillards brucircleacutes Insuffisants
reacutenaux cancer immunosupprimeacutes
bull Depuis alcool et diabegravete souvent aucun anteacuteceacutedent notable
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Facteurs et circonstances favorisant
bull Revue de 1988 pour les bacteacuterieacutemiesenfants et vieillards brucircleacutes Insuffisants
reacutenaux cancer immunosupprimeacutes
bull Depuis alcool et diabegravete souvent aucun anteacuteceacutedent notable
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Fasciite neacutecrosante
bull Infection des tissus sous cutaneacute profonds
bull Evolution rapide vers la neacutecrose en 24 -48 h
bull Mortaliteacute gt 50
bull Necrotizing soft tissue infection
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Fasciite neacutecrosante
bull A partir drsquoune plaie banale ou drsquoune incision chirurgicale ou sans plaie apparente
bull Rougeur se transformant en zone violaceacutee extensive avec apparition de bulles remplies de liquide heacutemorragique
bull Bacteacuterieacutemie freacutequente abcegraves meacutetastatique possible
bull Fiegravevre eacuteleveacutee prostration eacutetat de choc
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Signes drsquoalerte
bull Douleur anormalement eacuteleveacutee avec fiegravevre
bull Porte drsquoentreacutee piqucircre drsquoinsecte varicelle plaie traumatique beacutenigne incision chirurgicale brucirclure
bull Pas de porte drsquoentreacutee 50 Contusion musculaire simple
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Streptococcal toxic shock syndrome
bull 1) Preacutesence de S pyogenesa) site steacuterile sang LCR ascite tissus pfdsb) site non steacuterile ORL plaie superficielle
bull 2) hypotension lt90 mm Hg et 2 des signes suivants creacuteat gt 20 ml
thrombopeacutenie lt 100000 ou CIVDARDS ou fuite capillaireTransaminases gt 2x Neacuterythegraveme diffusfasciite neacutecrosante
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
LRINEC
bull CRP gt 150 4 pts
bull Hb entre 11 et 135g 1 pt
bull Hb lt 11 g 2 pts
bull Na lt 135 2 pts
bull Creacuteat gt 16 mg 2 pts
bull Glucose gt 180 mg 1 pt
bull GB entre 15 et 25 1 pt
bull GB gt 25 2 pt
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Lrinec au chu
fasciite 0 2 5 6 6 7 7 7 8 8 9
autre 0 1 1 1 2 2 3 4 5 5 6 6 8 8
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Graviteacute
bull fasciites 10 chocs sur 12 1 sepsis
bull Autres infections 3 chocs sur 18
bull Mortaliteacute des infections sans choc 0
bull Mortaliteacute des chocs 815 = 53
bull Dureacutee de vie des deacuteceacutedeacutes 12421111 j
bull Dureacutee de seacutejour des survivants 4424100686375125 j
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Deacuteceacutedeacutes
bull 1) 93 ans deacutemente domicile sepsis limitation de traitement
bull 2) 83 ans parkinson IRC domicile choc
bull 3) 72 ans opeacutereacutee la veille drsquoune cataracte revient pour fiegravevre et vomissements acidose IRA choc floride
bull 4) 69 ans cancer meacutetastatique sous chimio Amputation m inf puis limitation
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Deacuteceacutedeacutes
bull 5) 68 ans revient drsquoun seacutejour agrave la mer mal de gorge puis eacutetat de choc rapide
bull 6) 66 ans carcinomatose peacuteritoneacuteale sous chimio Infection drsquoascite avec bacteacuterieacutemie
bull 7) 67 ans zona Fiegravevre et malaise agrave domicile Appel intubation neacutecessaire et leacutevophed dans lrsquoambulance
bull 8) 36 ans eacutethylique refuse lrsquohospitalisation Infection eacutevidente Retour agrave domicile arca
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Prise en charge
bull Antibiotheacuterapie
bull Chirurgie
bull Traitement du choc remplissage + vasopresseurs
bull Immunoglobulines
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Antibiotheacuterapie
bull Empirique Large spectre C3 Augmentin + aminoside
bull Cibleacute peacutenicilline + Dalacin1) pas de reacutesistance agrave la peacutenicilline rare agrave la clindamycine2) clinda meilleure dans les modegraveles animaux3) pas drsquoantagonisme4) clinda inhibe formation prot M et exotoxines5) stade stationnaire dans les infections profondes6) post antibiotic effect
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Clin Infect Dis 2017 Apr 164(7)877-885 doi 101093cidciw871Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock A Propensity Score-Matched Analysis From 130 US HospitalsKadri SS12 Swihart BJ3 Bonne SL4 Hohmann SF56 Hennessy LV7 Louras P7 Evans HL7 Rhee C8 Suffredini AF1 Hooper DC2 Follmann DA3 Bulger EM7 Danner RL1Author informationAbstractBackground Shock frequently complicates necrotizing fasciitis (NF) caused by group A Streptococcus (GAS) or Staphylococcus aureus Intravenous immunoglobulin (IVIG) is sometimes administered for presumptive toxic shock syndrome (TSS) but its frequency of use and efficacy are unclearMethods Adult patients with NF and vasopressor-dependent shock undergoing surgical debridement from 2010 to 2014 were identified at 130 US hospitals IVIG cases were propensity-matched and risk-adjusted The primary outcome was in-hospital mortality and the secondary outcome was median length of stay (LOS)
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Results Of 4127 cases of debrided NF with shock at 121 centers only 164 patients (4) at 61 centers received IVIG IVIG subjects were younger with lower comorbidity indices but higher illness severity Clindamycin and vasopressor intensity were higher among IVIG cases as was coding for TSS and GAS In-hospital mortality did not differ between matched IVIG and non-IVIG groups (crude mortality 273 vs 236 adjusted odds ratio 100 [95 confidence interval 55-183] P = 99) Early IVIG (le2 days) did not alter this effect (P = 99) Among patients coded for TSS GAS andor S aureus IVIG use was still unusual (59868 [68]) and lacked benefit (P = 63) Median LOS was similar between IVIG and non-IVIG groups (26 [13-49] vs 26 [11-43] P = 84) Positive predictive values for identifying true NF and debridement among IVIG cases using our algorithms were 97 and 89 respectively based on records review at 4 hospitalsConclusions Adjunctive IVIG was administered infrequently in NF with shock and had no apparent impact on mortality or hospital LOS beyond that achieved with debridement and antibiotics
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Autres traitements
bull Immunoglobulines speacutecifiques
bull Heacutemoperfusion sur colonne adsorbant les exotoxines
bull Caisson hyperbare
bull Plasmapheacuteregravese
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Physiopathologie
bull Exacerbation de la reacuteponse de lrsquohocircte
bull Superantigegravenes et reacuteponse cytokinique
bull Virulence des bacteacuteriesadheacutesine pour muqueuse
pour musclescapsuleproteacuteine MStreptolysine O
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Lymphocytes circulant
bull Infection cutaneacutee non fasciite550 810 840 910 970 1110 1230 1690
1750 3280
bull Fasciite neacutecrosante et choc0 0 20 20 50 130 310 470 830 840
1280
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Fatal streptococcal toxic shock syndrome in a patient with rheumatoid arthritis treated withetanerceptUthman I Husari A Touma Z Kanj SS
Rheumatology (Oxford) 2005 Sep44(9)1200-1 Epub 2005 May 3
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Intern Med 201655(21)3211-3214 Epub 2016 Nov 1Recurrent Streptococcus agalactiae Toxic Shock Syndrome Triggered by a Tumor Necrosis Factor-α InhibitorYoshida M1 Takazono T Tashiro M Saijo T Morinaga Y Yamamoto K Nakamura S Imamura Y Miyazaki T Sawai T Nishino T Izumikawa K Yanagihara K Mukae H Kohno SAuthor informationAbstractStreptococcal toxic shock syndrome caused by group B streptococcus (GBS) isa rare but lethal disease We experienced a 45-year-old woman with pustularpsoriasis who developed toxic shock-like syndrome during infliximabtreatment Surprisingly similar episodes recurred three times in one year withrestarting of infliximab treatments In the third episode GBS were detected in blood urine and vaginal secretion cultures These episodes of shocksyndrome were possibly due to GBS To the best of our knowledge this is the first case report of recurrent streptococcal toxic shock syndrome possiblycaused by GBS which was induced by anti-TNF-α inhibitor therapy The restarting of biological agents in patients with a history of toxic shocksyndrome should therefore be avoided as much as possible
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Arguments contre le storm cytokinique
bull 1) on nrsquoen a pas mesureacute
bull 2) la stimulation clonale lymphocytaire nrsquoest pas rapporteacutee Il y a plutocirct une deacutepleacutetion lymphocytaire
bull 3) les anticorps anti TNF nrsquoont pas drsquoeffet
bull 4) la neacutecrose des tissus est speacutecifique des streptocoques
bull 5) on a drsquoautres explications
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
A BGroup A
streptococci
M protein released from bacterial
surfaceFibrinogen
M protein-fibrinogen aggregate
M protein
Endothelium
Vascular smooth
muscle
Polymorphonuclear
leukocyte
M protein-fibrinogen
aggregate
Degranulation
Respiratory burst
Endothelial damage
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Douleur aigueuml et neacutecrose tissulaire
bull Obstruction vasculaire par aggreacutegats de leucocytes et de plaquettes
- lrsquoinstallation et lrsquoextension des neacutecroses sont celles drsquoune obstruction arteacuterielle
- la douleur peut correspondre agrave un stop arteacuteriel
- les tissus atteints ne saignent pas- la microscopie reacutevegravele des thrombi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Virulence
bull Streptolysin O provoque aggreacutegats leucocytaire et
plaquettaireclive lrsquoIL8 et le C5a les plus puissants
cheacutemoattractantslyse les leucocytes
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
Conclusions
bull Infection laquo terrifiante raquo
bull Meacutecanismes partiellement eacutelucideacutes
bull Prise en charge urgente deacutecevante mais absolument neacutecessaire
bull Autres traitements qursquoantibiotiques attendus
bull Le choc septique nrsquoest pas une entiteacute en soi
