CRP20 ON THE BRINK: INVASIVE GROUP A STREPTOCOCCUS PRESENTING AS PEDIATRIC THORACIC CATASTROPHE

Fatin Farihah Nasir, Mohd Firdaus Arifin, Thavani A/P Thavarajasingam, Ani Suraya A.Rani
Hospital Putrajaya, Hospital Sultan Idris Shah

Introduction
Group A Streptococcus (GAS) is a highly adaptable pathogen, responsible for a spectrum of illnesses ranging from mild infections such as pharyngitis and scarlet fever to severe invasive diseases including necrotizing fasciitis and streptococcal toxic shock syndrome. In the post-COVID-19 era, a significant surge in GAS cases has been reported across Europe and parts of Asia. Although treatable, invasive GAS (iGAS) can progress swiftly and carries a high risk of mortality, particularly in the pediatric population.

Case Illustration
We present a case of a 2-year-old boy with a one-week history of fever, cough, and a blanchable erythematous macular rash. He presented in a pre-terminal state, requiring immediate resuscitation. Imaging and clinical assessment revealed stage II left-sided empyema thoracis, with 250 mL of exudative pleural fluid drained. His condition deteriorated rapidly, culminating in multiorgan failure involving renal, hepatic, and coagulation systems, as well as acute respiratory distress syndrome (ARDS) complicated by recurrent air leak syndrome. Despite intravenous immunoglobulin and broad-spectrum antibiotics, he remained in refractory septic shock, requiring multiple inotropes. Anuric acute kidney injury necessitated peritoneal dialysis. Ventilation was prolonged, and subsequent neuroimaging revealed hypoxic changes with small hemorrhages. PCR of pleural fluid confirmed Streptococcus pyogenes. Following an eight-week course of antibiotics and intensive supportive care, the patient showed gradual recovery.

Conclusion
This case underscores the fulminant nature of iGAS in children and the importance of early recognition, prompt microbiological diagnosis, and aggressive multidisciplinary intervention. Timely identification of the causative organism can be pivotal in guiding treatment and improving outcomes in life-threatening pediatric thoracic infections.