Article

Streptococcal toxic shock syndrome following insertion of an intrauterine device – A case report

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Abstract

Though the incidence of infection associated with the use of intrauterine devices (IUDs) is quite low, toxic shock syndrome (TSS) should be considered if fever and shock should develop rapidly following insertion of the device. A 31-year-old woman, para 4, developed fever, abdominal pain, nausea and vomiting two days after insertion of a CuT380A copper IUD. Six days after insertion the patient fulfilled the criteria for TSS. She presented evidence of an acute pelvic infection for which an emergency total abdominal hysterectomy with bilateral salpingectomy was performed. The sepsis appeared to be due to group A streptococcus (GAS). The patient made an uneventful recovery. This is the first reported case of GAS causing a TSS associated with insertion of an IUD. Streptococcal TSS can be fatal. Early aggressive management is mandatory.

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... The reason for sep c shock in this woman may be underlying genital infec on at the me of CU-T inser on as sep caemia occurred only a er that and there was Bartholin abscess no ced or incised during delivery. Unusual complica ons of postpartum CU-T may be sepsis, sep c shock 7 and toxic shock syndrome. ...
... Moreover, GAS colonizes the vagina, especially in women with lactational amenorrhea, menopausal women, and prepubescent girls [7][8][9], and vaginitis caused by GAS can progress to STSS [10]. Few studies reported that STSS caused by an ascending vaginal GAS infection may develop after interventional procedures, such as endometrial biopsy, intrauterine contraceptive device insertion, or hysteroscopy [11][12][13][14][15]. However, cytocervical sampling has not yet been recognized as a predisposing cause of STSS. ...
Article
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Streptococcal toxic shock syndrome (STSS) is a life-threatening illness mainly caused by invasive group A Streptococcus (GAS) infection. Herein, we report a case of a postmenopausal woman who developed STSS from an ascending vaginal GAS infection after cytocervical sampling. The patient complained of vaginal discharge, for which she underwent gynecological examination with vaginal sampling. The following day, there was onset of diarrhea and vomiting. After 7 days, she was admitted to our hospital with septic shock. Necrotizing enterocolitis was suspected and surgical intervention was performed; however, the patient was diagnosed with primary peritonitis and antibiotics were initiated. On day 2, GAS was suspected by blood cultures, and antibiotics were changed in consideration of STSS. On day 4, GAS was confirmed in blood, ascitic fluid, and vaginal swab specimens, and STSS caused by an ascending vaginal GAS infection was diagnosed. This case report indicates that STSS could occur following cytocervical sampling for vaginal discharge. If a woman has unexplained septic shock, especially with gastroenteritis symptoms, STSS should be considered as a differential diagnosis.
... The patient described by Gisser et al ultimately had two exploratory laparotomies, a bilateral salpingectomy and a total abdominal hysterectomy due to the severity of her infection. Furthermore, Venkataramanasetty et al 18 reported the first case of GAS causing TSS after insertion of a copper IUD, which resulted in an emergent total abdominal hysterectomy with bilateral salpingectomy. Other serious complications after insertion of an IUD have been described as well, including severe adnexitis, 19 peritonitis and salphingitis. ...
Article
Intrauterine devices (IUDs) are rarely associated with serious infections. We report an unusual concomitant infection of group A Streptococcus (GAS) causing toxic shock syndrome and pelvic abscess with Actinomyces odontolyticus associated with an IUD in a healthy 50- year-old patient. The IUD was subsequently removed and the patient recovered on the appropriate antibiotics. This case highlights the importance of clinicians' high index of suspicion of an IUD infection and prompt removal of the infected foreign body to obtain source control.
... Sepsis after insertion of an IUD is a rare condition. The few cases found described in literature referred to toxic shock syndrome after IUD insertion caused by Streptococcus group A (8,9) and Staphylococcus aureus (10). We haven't found any case reporting meningococcal sepsis after an IUD insertion. ...
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Neisseria meningitidis is a normal commensal of human mucous membranes that is no longer considered to be restricted to the nasopharynx. Due to the practice of oral sex, the mucous membranes of the cervix, urethra or anus have become a potential infection site for this bacterium. Inserting an intrauterine device (IUD), can alter the protective barrier of the endocervical mucosa, allowing for bacterial infection and systemic spread. We present a case report of a 40-year-old woman who presented with abdominal pain, spotting and fever after inserting an IUD and developed a fulminant septical shock. Blood cultures and cultures from ascites showed the presence of Neisseria meningitidis group Y. From our knowledge, there are a few cases presented in the literature of toxic shock syndrome after IUD insertion, caused by Staphylococcus aureus or Streptococcus group A, but this is the first case of meningococcal sepsis after IUD insertion described. So, even though IUDs rarely cause significant infection, physicians should consider this device as a possible source in reproductive-aged women with the clinical features of sepsis.
Article
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A 44-year-old Caucasian female with a history of endometriosis is admitted to the intensive care unit due to severe left lower quadrant abdominal pain, nausea and vomiting. With patients’ positive chandelier sign on pelvic examination, leucocytosis, elevated erythrocyte sedimentation rate and elevated C-reactive protein indicated that she had pelvic inflammatory disease (PID). PCR tests were negative for Neisseria gonorrhoeae and Chlamydia trachomatis ; however, her blood and urine cultures grew Group A streptococci (GAS) with a negative rapid Streptococcus throat swab and no known exposure to Streptococcus . On further review, patient met criteria for GAS toxic shock syndrome based on diagnostic guidelines. The patient was promptly treated with intravenous antibiotics and supportive care, and she acutely recovered. This case demonstrates a rare cause of PID and an atypical aetiology of severe sepsis. It illuminates the importance of considering PID as a source of infection for undifferentiated bacteraemia.
Article
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Rationale: Several reports describe severe group A streptococcal (GAS) infections causing septic shock, soft-tissue necrosis, and multiple organ failure known as streptococcal toxic shock syndrome (STSS). However, primary peritonitis with GAS is rare and most of them were undertaken surgical procedure. Patient concerns: We herein reported the case of 26-year-old healthy woman with sudden severe abdominal pain and hypotension. Computed tomography (CT) showed that large amount of free fluid in the peritoneal cavity consist with peritonitis, and no free air. Diagnoses: Primary peritonitis with GAS. Interventions: Proper antibiotic therapy according to blood culture results. Outcomes: After antibiotic therapy, the patient recovered well without complications. Lessons: An appropriate diagnostic approach and prompt antibiotic therapy is essential in GAS primary peritonitis.
Article
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We herein report the case of a 66-year-old woman presenting with symptoms of gastroenteritis. Computed tomography showed small-bowel dilation without ischemic signs. After admission, she went into shock and was treated for sepsis of unknown origin. She was later diagnosed with group A streptococcal peritonitis due to an ascending vaginal infection. This case highlights the importance of considering Group A Streptococcus (GAS) infection as a cause of peritonitis in postmenopausal women.
Article
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Background Streptococcus pyogenes can colonize genitourinary tract, but it is a rare cause of salpingitis. Case report We report a case of bilateral salpingitis due to Streptococcus pyogenes in a 34-year-old woman using an intra-uterine device and which occurred following a family history of recurrent S. pyogenes infections. We review 12 other cases reported in the literature, and discuss the pathophysiological mechanisms of this potentially life-threatening disease. Conclusion It is important to take into account consider Streptococcus pyogenes as a cause of acute salpingitis in the context of recent intra-familial Streptococcus pyogenes infections.
Chapter
Minimally invasive gynecologic surgery—laparoscopy and hysteroscopy—is increasingly common, and providers should be prepared to assess patients immediately postoperatively and when they return with urgent issues. The differential diagnosis and initial steps in the assessment of postoperative fever, pain, and nausea are provided in this chapter. Management of infectious complications (including wound infections, abscesses, toxic shock syndrome, necrotizing fasciitis, urinary tract infections, and pneumonia), thrombotic morbidity, urinary or gastrointestinal tract injuries, vaginal cuff dehiscence, nerve injuries, and complications specific to hysteroscopy are all discussed.
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This chapter focuses on progestogen-only implants and intrauterine devices. These methods have a high effectiveness with pregnancies being rare, however intrauterine devices can be expelled. The inherent safety of both types of device is good. Implants and hormone-releasing intrauterine devices can produce hormonal side effects but also non-contraceptive benefits. The levonorgesetrel intrauterine system is widely used in the treatment of heavy menstrual bleeding. Contraceptive devices often cause changes in menstrual bleeding which may result in discontinuation of the method. There are some risks associated with insertion and removal of implants with scope for their reduction. Perforation of the uterus with intrauterine devices is rare, difficult to prevent but usually relatively straightforward to manage. Return to fertility after all contraceptive devices is rapid. Transdermal patches and vaginal rings are also mentioned in the chapter. While these non-oral routes of combined hormonal contraception administration are considered to be safe, side effects are generally greater than with oral preparations.
Article
Streptococcal toxic shock syndrome (TSS) is a systemic illness usually caused in the setting of infection by group A Streptococcus (GAS). The primary infections are often invasive infections of the respiratory tract or necrotizing infections of the skin and soft tissue, but some infections occur without relevant focus. GAS vaginitis is a rare condition among adult women and is accordingly thought to be uncommon as a cause of streptococcal TSS. Here we report the cases of two postmenopausal women with streptococcal TSS secondary to GAS vaginitis, one aged 55 and one aged 60. Both came to our emergency department with complaints or symptoms of abdominal pain, fever, hypotension, and multi-organ failure. In both cases, the relevant factor associated with streptococcal infection was a recent episode of GAS vaginitis. Both underwent fluid management and 14 days of antibiotic treatment and fully recovered without complications. Vaginitis was likely to be the primary infectious trigger of TSS in these two cases. Intrauterine device insertion, endometrial biopsy, and post-partum state have all been previously reported in TSS patients, and the female genital tract has been described as a portal of entry. GAS vaginitis warrants appropriate treatment as it may progress to severe systemic infection as described.
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Group A streptococcal (GAS) toxic shock syndrome (TSS) is an uncommon, but life-threatening infection during pregnancy and should be considered in rapid onset of shock. Most cases described in the literature have occurred in the puerperium. We report a case of GAS TSS occurring during the third trimester of pregnancy in a previously healthy woman. A 31-year-old female, who was 34 weeks pregnant, presented with fevers and a prodromal 'flu-like' illness. She rapidly developed shock and multiorgan failure. Blood cultures revealed GAS bacteremia and the patient met criteria for streptococcal TSS. Despite her eventual recovery, her infant died on postpartum day 15 as a consequence of the mother's TSS. This case is unusual in that there were no identifiable initiating events or source of the streptococcal infection, and the TSS developed during pregnancy rather than after delivery. Early recognition of GAS infections is important given the rapid onset and high morbidity and mortality associated with these infections. This is the first reported case utilizing intravenous immunoglobulin for GAS TSS in the puerperium.
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GROUP A streptococcus (Streptococcus pyogenes) may cause a variety of illnesses ranging from very common, usually clinically mild conditions such as pharyngitis and impetigo to less common severe infections including septicemia and pneumonia. In 1987, Cone et al1 described two patients with severe group A streptococcal infections having clinical features similar to the staphylococcal toxic shock syndrome. This syndrome, designated the "streptococcal toxic shock—like syndrome" or the "toxic streptococcal syndrome,"2 was further characterized by Stevens et al3 in a series of 20 patients. Most patients included in this series were less than 50 years old and otherwise healthy. All had invasive group A streptococcal infections characterized by signs including shock, multi—organ system involvement, and rapidly progressive, destructive soft-tissue infection (necrotizing fasciitis). The case-fatality rate was 30% even though most patients received appropriate antimicrobial therapy, supportive care, and, where necessary, surgical débridement. Ten available isolates were serotyped and
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The late 1980s have witnessed the emergence of severe group A streptococcus (GAS) infection; shock, bacteremia, and acute respiratory distress syndrome are common features, and death has been associated with this infection in 30% of patients. Such infections have now been described in all parts of the United States, Europe, and Australia and have occurred predominantly in otherwise healthy adolescents and adults. The characteristic clinical and laboratory features of the streptococcal toxic shock syndrome include deep-seated infection associated with shock and multiorgan failure. Strains of GAS isolated from patients with invasive disease have been predominantly M types 1 and 3, which produce pyrogenic exotoxin A or B or both. In this report, the clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis will be presented and compared with those of streptococcal toxic shock syndrome. Current concepts of the pathogenesis of invasive streptococcal infection will also be presented in terms of the interaction between virulence factors of GAS and host defense mechanisms. Finally, new concepts for future treatment of serious streptococcal infections will be proposed.
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The IUD has undergone numerous modifications and innovations since the Graefenberg ring of the early 1900s. This and the other small rings were initially designed so as to introduce a foreign body of minimal size into the uterine cavity. Larger plastic devices, introduced in the 1960s (e.g., Lippes Loop, Birnberg bow, Margulies Spiral), were purported to have lower pregnancy and expulsion rates. Monofilament tails were also added because the ease of detection and extraction of the IUD allowed by the tail was felt to be more important than the risk of potential infection. With the development of the Dalkon Shield in the late 1960s came a new era in IUD development. The A.H. Robins Company, developers of the Shield, elected to add a sheathed multifilament tail which, over the next 4 years, resulted in 242 spontaneous midtrimester septic abortions in women wearing the Shield; only 37 women not wearing a Dalkon Shield experienced this event. 10 maternal deaths resulted. Salpingitis and pelvic inflammatory disease (PID) were other serious results of IUD wear. Consequently, IUD use in the US and worldwide dropped. Of major import was the finding that, when compared to noncontraceptors, the relative risk of PID was 15.6 for longterm Dalkon Shield users and only 1.5 for longterm users of other types of IUDs. When Dalkon Shield data are extracted, there remains a very low rate of serious complications resulting from IUD wear. The problem with the Dalkon Shield has encouraged more research in the direction of the tailless IUD. The development of the small T-shaped IUD came as an attempt to have a device which was adapted to the size and shape of the uterine cavity rather than the other way around. To this was added copper to enhance the contraceptive effect. Copper-medicated IUDs, among them the Copper 7, Nova-T, and the Multiload, were added to the list of available IUDs. Progestogens have been now incorporated with the plain T. This has resulted in the Progestasert and the Levonorgestrel T, both of which effect a reduction in menstrual blood loss. While major advances have been made in the field of intrauterine contraception, more innovations and improvements can be expected in the future.
Article
To measure and compare the incidence of adverse events during use of two medicated intrauterine devices (IUDs). A multicenter prospective 7-year randomized study. Family planning clinics, primarily in developing countries. Women age 18 to 38 years at admission, desiring contraception and without contraindications to IUDs. Incidence of complaints, conditions, and rates of specific termination for each IUD. Subjects recorded menstrual events, and clinical staff registered all complaints and conditions found on examination at four first-year clinic visits and at semiannual visits thereafter. Difference in rates were analyzed by chi 2 statistics. Annual pregnancy rates for each IUD averaged 0.2/100 women whereas upper genital tract infection occurred at rates of 0.6 to 0.7 per 100 years of use. The levonorgestrel-releasing IUD significantly decreased bleeding and spotting days in comparison with historical data for noncontraceptors and with the copper-medicated IUD. Dysmenorrhea, vaginitis, and myoma in women with the levonorgestrel IUD were markedly decreased in comparison with the experience of copper IUD users. Significantly higher rates of amenorrhea, delayed ovarian follicular atresia, skin and hair conditions, and headache were observed with the steroid IUD than with the copper-releasing IUD. Rates of reported adverse effects for either IUD were highest in the first 2 years of use and among women under age 25. Long-term use of copper or levonorgestrel IUDs is characterized by very low rates of pregnancy and by a low and declining annual incidence of side effects, including pelvic infection and borderline anemia. The levonorgestrel-releasing IUD reduced the incidence of bleeding and, in the long term, of myoma and myoma-related surgery in comparison with the copper T IUD. Both IUDs proved highly acceptable and had few unanticipated side effects.
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Concern about upper-genital-tract infection related to intrauterine devices (IUDs) limits their wider use. In this systematic review I summarise the evidence concerning IUD-associated infection and infertility. Choice of an inappropriate comparison group, overdiagnosis of salpingitis in IUD users, and inability to control for the confounding effects of sexual behaviour have exaggerated the apparent risk. Women with symptomless gonorrhoea or chlamydial infection having an IUD inserted have a higher risk of salpingitis than do uninfected women having an IUD inserted; however, the risk appears similar to that of infected women not having an IUD inserted. A cohort study of HIV-positive women using a copper IUD suggests that there is no significant increase in the risk of complications or viral shedding. Similarly, fair evidence indicates no important effect of IUD use on tubal infertility. Contemporary IUDs rival tubal sterilisation in efficacy and are much safer than previously thought.
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Toxic shock syndrome is a rare but potentially fatal toxin-mediated febrile illness. Although classically associated with tampon use, it is now known that many nonmenstrual conditions are related to this syndrome. Serious morbidity and mortality can occur if this syndrome is not promptly recognized. MEDLINE was searched from 1978 to the present using the phrase "toxic shock syndrome." Case reports and articles related to tampon-associated toxic shock syndrome were excluded from the literature review except when defining toxic shock syndrome or discussing the cause of the syndrome. A case of nonmenstrual toxic shock syndrome associated with an intrauterine device and a review of the definition, cause, diagnostic criteria, and management are reported. Toxic shock syndrome can mimic many common diseases. Because it can be associated with a number of nonmenstrual-related conditions, patients with unexplained fever and rash and a toxic condition out of proportion to local findings should have the diagnosis of toxic shock syndrome in their differential diagnosis. Early recognition and aggressive management can decrease the overall morbidity and mortality.
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With the goal of helping clinicians facilitate contraceptive success for their patients, this Clinical Opinion provides an update regarding older hormonal and intrauterine contraceptives and details newer methods that include the progestin-releasing intrauterine system, the contraceptive patch and ring, and extended and emergency oral contraception. Last, I will look over the horizon and briefly describe potential future methods that include the single rod progestin-releasing implant, folic acid-supplemented oral contraceptives, and hormonal contraception for men.
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Toxic shock syndrome (TSS) is caused by Staphylococcus aureus infection. The disease entity manifests clinically as fever, hypotension, diffuse macular erythema that progresses to desquamation, and dysfunction of > 3 organ systems. Toxic shock-like syndrome (TSLS) has the same clinical manifestation as TSS but is caused by Streptococcus, usually group A, C or G. Here we report on a healthy woman who experienced group B Streptococcus (GBS)-related TSLS, possibly related to tampon use. A 37-year-old woman, gravida 1, para 1, met the diagnostic criteria for TSS/TSLS 5 days after her last tampon use. Blood, urine and vaginal cultures were positive only for GBS. Analysis of the blood isolate suggested a novel GBS superantigen. This is the second reported case of GBS causing tampon-associated TSS/TSLS. Up to 40% of healthy menstruating women are vaginally colonized with GBS. Superantigens elaborated by staphylococci and streptococci induce an immunologic mediator storm that affects the circulatory and end-organ systems to produce the clinical picture. Prompt medical therapy involves large-volume isotonic fluid resuscitation and antibiotic coverage with vancomycin and an antistaphylococcal beta-lactam. Clindamycin may dampen the immunologic response and endotoxin production. Corticosteroids and intravenous immunoglobulin may be useful adjuncts; however, nonsteroidal antiinflammatories should be avoided.
Article
The clinical diagnosis of a pelvic inflammatory disease (PID) is notoriously difficult. The incidence rate of PIDs among intrauterine device (IUD) users as reported from different studies depends heavily on the definition used and the means available for diagnosing PIDs. It varies by almost 10-fold from 1 per 100 to 1 per 1000 woman-years in different publications. PID risk has been found to be 6-fold higher in the first month after IUD insertion than it is thereafter. It is not known if the overall PID risk in IUD users beyond the first month of IUD insertion is higher than that in nonusers; however, if it is higher, the additional risk is small. The PID risk in IUD users is modified by the number of sexual partners of the IUD user and that of her partner(s), community prevalence of STDs and age of the IUD user. Bacterial vaginosis appears not to be associated with IUD use. Overall, bacterial vaginosis is not associated with PIDs, but specific subgroups of patients with BV that may be difficult to identify clinically are at an increased risk for PIDs. Because of the long duration of use of current copper IUDs, replacement of the IUD is infrequent and insertion-associated PIDs should consequently also be less frequent. IUD use has become safer with respect to PIDs through more effective screening and counseling procedures described in current guidelines for the initiation of IUD use. Current guidance must be followed to preserve the IUD as a safe contraceptive method.