Skip to main content

A case of streptococcal toxic shock syndrome due to Group G streptococci identified as Streptococcus dysgalactiae subsp. equisimilis


A 79-year-old man with a 3-month history of lymphedema of the lower limbs, and diabetes mellitus, was admitted to our hospital for suspected deep venous thrombosis. Several hours after admission, leg pain and purpura-like skin color appeared. On the 2nd hospital day, he was referred to our department for possible acute occlusive peripheral artery disease (PAD) and skin necrosis with blisters; however, computed tomography with contrast showed no occlusive lesions. He had already developed shock and necrotizing deep soft-tissue infections of the left lower leg. Laboratory findings revealed renal dysfunction and coagulation system collapse. Soon after PAD was ruled out, clinical findings suggested necrotizing deep soft-tissue infections, shock state, disseminated intravascular coagulation, and multiple organ failure. These symptoms led to a high suspicion of the well-recognized streptococcal toxic shock syndrome (STSS). With a high suspicion of STSS, we detected Group G β-hemolytic streptococci (GGS) from samples aspirated from the leg bullae, and the species was identified as Streptococcus dysgalactiae subsp. equisimilis (SDSE) by 16S-ribosomal RNA sequencing. However, unfortunately, surgical debridement was impossible due to the broad area of skin change. Despite adequate antimicrobial therapy and intensive care, the patient died on the 3rd hospital day. The M-protein gene (emm) typing of the isolated SDSE was revealed to be stG6792. This type of SDSE is the most frequent cause of STSS due to GGS in Japan. We consider it to be crucial to rapidly distinguish STSS from acute occlusive PAD to achieve life-saving interventions in patients with severe soft-tissue infections.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. Vartian C, Lerner PI, Shlaes DM, Gopalakrishna KV. Infections due to Lancefield group G streptococci. Medicine (Baltimore). 1985;64:75–88.

    CAS  Google Scholar 

  2. Takahashi T, Asami R, Tanabe K, Hirono Y, Nozawa Y, Chiba N, Ubukata K. Clinical aspects of invasive infection with Streptococcus dysgalactiae subsp. equisimilis in elderly patients. J Infect Chemother. 2010;16:68–71.

    PubMed  Article  Google Scholar 

  3. Taylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M, Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation—on behalf of the Scientific Subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haemostasis (ISTH). Thromb Haemost. 2001;86:1327–30.

    PubMed  CAS  Google Scholar 

  4. The Working Group on Severe Streptococcal Infections; Breiman RF, Davis JP, Facklam RR, Gray BM, Hoge CW, Kaplan EL, Mortimer EA, Schlievert PM, Schwartz B, Stevens DL, Todd JK. Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA. 1993;269:390–1.

    Google Scholar 

  5. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373–406.

    PubMed  Article  Google Scholar 

  6. Kageyama A, Torikoe K, Iwamoto M, Masuyama J, Shibuya Y, Okazaki H, Yazawa K, Minota S, Kroppenstedt RM, Mikami Y. Nocardia arthritidis sp. nov., a new pathogen isolated from a patient with rheumatoid arthritis in Japan. J Clin Microbiol. 2004;42:2366–71.

    PubMed  Article  CAS  Google Scholar 

  7. Beall B, Facklam R, Thompson T. Sequencing emm-specific PCR products for routine and accurate typing of group A streptococci. J Clin Microbiol. 1996;34:953–8.

    PubMed  CAS  Google Scholar 

  8. Ikebe T, Murayama S, Saitoh K, Yamai S, Suzuki R, Isobe J, Tanaka D, Katsukawa C, Tamaru A, Katayama A, Fujinaga Y, Hoashi K, Working Group for Streptococci in Japan. Surveillance of severe invasive group-G streptococcal infections and molecular typing of the isolates in Japan. Epidemiol Infect. 2004;132:145–9.

    PubMed  Article  CAS  Google Scholar 

  9. Vandamme P, Pot B, Falsen E, Kersters K, Devriese LA. Taxonomic study of lancefield streptococcal groups C, G, and L (Streptococcus dysgalactiae) and proposal of S. dysgalactiae subsp. equisimilis subsp. nov. Int J Syst Bacteriol. 1996;46:774–81.

    PubMed  Article  CAS  Google Scholar 

  10. Gerlach D, Köhler W, Günther E, Mann K. Purification and characterization of streptolysin O secreted by Streptococcus equisimilis (group C). Infect Immun. 1993;61:2727–31.

    PubMed  CAS  Google Scholar 

  11. Humar D, Datta V, Bast DJ, Beall B, De Azavedo JC, Nizet V. Streptolysin S and necrotising infections produced by group G streptococcus. Lancet. 2002;12(359):124–9.

    Article  Google Scholar 

  12. Ravins M, Jaffe J, Hanski E, Shetzigovski I, Natanson-Yaron S, Moses AE. Characterization of a mouse-passaged, highly encapsulated variant of group A streptococcus in in vitro and in vivo studies. J Infect Dis. 2000;182:1702–11.

    PubMed  Article  CAS  Google Scholar 

  13. Fischetti VA. Streptococcal M protein: molecular design and biological behavior. Clin Microbiol Rev. 1989;2:285–314.

    PubMed  CAS  Google Scholar 

  14. Schnitzler N, Podbielski A, Baumgarten G, Mignon M, Kaufhold A. M or M-like protein gene polymorphisms in human group G streptococci. J Clin Microbiol. 1995;33:356–63.

    PubMed  CAS  Google Scholar 

  15. Hashikawa S, Iinuma Y, Furushita M, Ohkura T, Nada T, Torii K, Hasegawa T, Ohta M. Characterization of group C and G streptococcal strains that cause streptococcal toxic shock syndrome. J Clin Microbiol. 2004;42:186–92.

    PubMed  Article  CAS  Google Scholar 

  16. Takahashi T, Ubukata K, Watanabe H. Invasive infection caused by Streptococcus dysgalactiae subsp. equisimilis: characteristics of strains and clinical features. J Infect Chemother. 2011;17:1–10.

    PubMed  Article  CAS  Google Scholar 

  17. Sunaoshi K, Murayama SY, Adachi K, Yagoshi M, Okuzumi K, Chiba N, Morozumi M, Ubukata K. Molecular emm genotyping and antibiotic susceptibility of Streptococcus dysgalactiae subsp. equisimilis isolated from invasive and non-invasive infections. J Med Microbiol. 2010;59:82–8.

    PubMed  Article  CAS  Google Scholar 

  18. Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis. 1992;14:2–11.

    PubMed  Article  CAS  Google Scholar 

  19. Takahashi T, Sunaoshi K, Sunakawa K, Fujishima S, Watanabe H, Invasive Streptococcal Disease Working Group. Clinical aspects of invasive infections with Streptococcus dysgalactiae ssp. equisimilis in Japan: differences with respect to Streptococcus pyogenes and Streptococcus agalactiae infections. Clin Microbiol Infect. 2010;16:1097–103.

    PubMed  Article  CAS  Google Scholar 

  20. Stevens DL, Tanner MH, Winship J, Swarts R, Ries KM, Schlievert PM, Kaplan E. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989;321:1–7.

    PubMed  Article  CAS  Google Scholar 

Download references

Conflict of interest

None of the authors have financial relationships with any commercial entity with an interest in the subject of this manuscript.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Takahito Nei.

About this article

Cite this article

Nei, T., Akutsu, K., Shima, A. et al. A case of streptococcal toxic shock syndrome due to Group G streptococci identified as Streptococcus dysgalactiae subsp. equisimilis . J Infect Chemother 18, 919–924 (2012).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Streptococcal toxic shock syndrome (STSS)
  • Group G streptococci
  • Streptococcus dysgalactiae subsp. equisimilis (SDSE)
  • M protein