A 9-year-old boy with pharyngitis for 7 days, and high fever and arthralgias in the 48 hours prior to admission. After 12 hours on the ward, he was admitted to the Intensive Care Unit (ICU) in a dazed state, with punctate petechial rash predominantly in the root of the limbs, poor peripheral perfusion, hypotension, tachycardia, increased work of breathing, desaturation and oligoanuria. Complementary examinations revealed leukopenia (3,600/mm3), plateletopenia (22. 000/mm3), C-reactive protein (11.96 mg/dl), Na+: 131 mEq/l, creatinine: 2.35 mg/dl, in anuria; coagulopathy with activated partial thromboplastin time: 58 sec (control: 30 sec), prothrombin time: 31 sec (control: 11 sec), Quick's index: 20%, fibrinogen: 269 mg/dl; antithrombin-III activity: 30%; liver dysfunction (aspartate aminotransferase: 306 IU/l, alanine aminotransferase: 184 IU/l, total bilirubin: 9 mg/dl, direct bilirubin: 6 mg/dl), metabolic acidosis (pH: 7.19, HCO3-: 16 mEq/l; EB: -10 mEq/l; lactate: 13 ng/dl and chest X-ray with bilateral alveolo-interstitial involvement.
Expansion, administration of sodium bicarbonate, antibiotics (cefotaxime and teicoplanin) and catecholamine perfusion (dopamine 5 µg/kg/min and noradrenaline up to 8 µg/kg/min) were started. Intubation and connection to mechanical ventilation was required due to worsening gas exchange with high respiratory support. Continuous venovenous haemofiltration was started due to renal failure and blood volume overload.
The evolution was unfavourable towards refractory multiple organ failure (MOF), producing asystole and cardiorespiratory arrest, with exsitus 12 hours after admission.
S. pyogenes serotype M1T1 was isolated in blood culture and bronchial aspirate.