Group A streptococcal infections: Formidable foes in the ICU. Presenting signs can mask advanced disease

Toxic shock syndrome and necrotizing fasciitis ("flesh-eating disease") are the most feared, lethal presentations of group A streptococcal (GAS) infection. The worst cases can manifest severe physiologic derangement and multiple organ failures. A generalized erythematous macular rash in a patient with signs of septic shock, or frank soft tissue necrosis or gangrene should raise suspicion of streptococcal toxic shock syndrome. In differentiating early necrotizing fasciitis from cellulitis and uncomplicated soft tissue injury, severe pain in the setting of a normal appearance or modest local changes may be the most distinguishing feature. Although supportive care is similar to that used for other severe infections, optimal treatment may require antibiotics such as clindamycin rather than those used in standard broad-spectrum regimens. The definitive test for GAS necrotizing fasciitis is tissue biopsy, and the mainstays of therapy are debridement and, if necessary, amputation.