(724) A Case of Invasive Group A Streptococcus and Influenza Coinfection in a Child Rescued With ECMO

Introduction: Invasive group A streptococcal (iGAS) infection is uncommon but associated with significant morbidity and mortality, which can be increased as high as 70% with concurrent influenza infection. Late 2022 into 2023 has seen a global surge of iGAS and respiratory viral infections compared to pre-COVID-19 pandemic levels. Few pediatric case reports of this co-infection exist and these rarely describe management with veno-arterial extracorporeal membranous oxygenation (VA-ECMO).

Description: Five days after being diagnosed with influenza A, a 7 y.o. previously healthy female presented with hypoxemic respiratory failure, fluid refractory hypotension, profound lactic acidosis, renal and hepatic failure, disseminated intravascular coagulation, and a widespread erythematous, petechial rash. Despite intubation, inotropic support, and broad-spectrum antibiotics, she progressed to cardiac arrest. After return of spontaneous circulation and within 24 hours of admission, she was cannulated to VA-ECMO. Streptococcal toxic shock syndrome was diagnosed following Streptococcus pyogenes positive blood and pleural fluid cultures. Antibiotics were transitioned to clindamycin and penicillin. Echocardiogram revealed severe biventricular dysfunction and she required dialysis due to oliguric renal failure. Following slow recovery, she was decannulated on ECMO day 12. After a 26-day PICU admission, she was transferred out of the ICU off all respiratory, cardiac, and renal support. Her iGAS infection caused bilateral lower extremity purpura fulminans leading to acral necrosis and requiring amputation of the right midfoot. After a 144-day hospitalization, she was discharged to an inpatient rehab facility and is expected to regain full strength and mobility.

Discussion: In this notable case, early implementation of ECMO preserved perfusion for the time needed to reach diagnosis, potentially mitigating the profound morbidity and mortality associated with her dangerous co-infection of iGAS and influenza. With the associated mortality and the increased likelihood for coinfection given recent high rates of both iGAS and respiratory viral infections, the early implementation of ECMO should be considered in the treatment algorithm for these patients given its feasibility and potential for profound benefit.