FROM PERIORBITAL CELLULITIS TO STREPTOCOCCAL TOXIC SHOCK SYNDROME: CASE REPORT IN AN IMMUNOCOMPROMISED PATIENT

Streptococcal toxic shock syndrome (STSS) is a severe, rare condition with high mortality, associated with invasive Streptococcus pyogenes infections, with rapid progression to multiorgan failure, especially in immunocompromised patients. We report the case of a 45-year-old woman with a history of human immunodeficiency virus (HIV) infection with irregular treatment, CD4 count of 142 cells/mm³ and viral load of 116,000 copies, as well as depression, ovarian neoplasm, and osteosarcoma previously treated with chemotherapy. She was admitted with preseptal cellulitis of the left eye, with two days of evolution. Treatment with ceftriaxone and oxacillin was started. The following day, she developed septic shock, and vancomycin plus prophylactic sulfamethoxazole-trimethoprim were introduced. Due to acute kidney injury, vancomycin was replaced with daptomycin and clindamycin was added to inhibit streptococcal toxin production. Eyelid edema hindered ophthalmologic assessment. Topical tobramycin was used. On the fifth day, blood cultures confirmed Streptococcus pyogenes, and penicillin G was started, with clindamycin maintained. The patient developed acute respiratory failure due to hypertensive acute pulmonary edema and required intubation. Chest CT showed extensive consolidations and ground-glass opacities. With viral causes ruled out, treatment for Pneumocystis jirovecii pneumonia with sulfamethoxazole-trimethoprim and hydrocortisone was initiated, leading to clinical improvement and reduced inflammatory markers. Four proning sessions were performed due to acute respiratory distress syndrome, with good ventilatory response. After completion of treatment for pneumocystosis, she developed new clinical worsening, with fever, purulent tracheal secretion and elevated inflammatory markers. Ventilator-associated pneumonia was diagnosed, and meropenem was started and maintained after isolation of Pseudomonas aeruginosa in tracheal secretion. Tracheostomy was performed due to prolonged intubation. She evolved with clinical improvement, remained on a ward, breathing room air, with a metal tracheostomy tube occluded and speaking. She is hemodynamically stable, with preserved renal function and antiretroviral therapy restarted (ritonavir, darunavir, and dolutegravir). This case illustrates the severity of STSS in immunosuppressed patients, emphasizing the importance of early recognition, appropriate antibiotic therapy, and multidisciplinary management.