Indian Journal of Critical Care Medicine

Register      Login



Volume / Issue

Online First

Related articles

VOLUME 16 , ISSUE 1 ( January, 2012 ) > List of Articles


Use of intravenous immunoglobulin therapy in the treatment of septic shock, in particular severe invasive group A streptococcal disease

Ajay H. Raithatha, Daniele C. Bryden

Keywords : Group A streptococcal disease, immunomodulation, intravenous immunoglobulin, septic shock

Citation Information : Raithatha AH, Bryden DC. Use of intravenous immunoglobulin therapy in the treatment of septic shock, in particular severe invasive group A streptococcal disease. Indian J Crit Care Med 2012; 16 (1):37-40.

DOI: 10.4103/0972-5229.94433

License: CC BY-ND 3.0

Published Online: 01-06-2018

Copyright Statement:  Copyright © 2012; The Author(s).


Group A streptococcus (GAS) is a β-hemolytic bacterium often found in the throat and skin. The two most severe clinical manifestations of GAS are streptococcal toxic shock syndrome and necrotizing fasciitis. Intravenous immunoglobulin (IVIg) is a gamma globulin made from purified pooled plasma of thousands of donors, consisting mainly of IgG. We report the case of a 40-year-old man admitted after 2 days of vomiting and severe right-sided chest pain. He was hypotensive with a sinus tachycardia, pyrexial, and vasodilated. The only other positive finding was a swollen and erythematous chest wall. Muscle layer biopsies and blood cultures soon grew extensive GAS, and an initial diagnosis of necrotizing fasciitis was made. The clinical syndrome was of severe septic shock secondary to invasive GAS. The patient quickly deteriorated with a worsening metabolic acidosis. Despite maximal intensive care therapy including fluids, vasoactive agents, and also activated protein C, the patient continued to remain profoundly hypotensive. A decision was made to commence IVIg, with the aim of immunomodulation of the inflammatory cascade seen in sepsis. Over the next 24 hours the patient improved, was extubated 3 days later, and subsequently discharged from hospital after 2 weeks. Although the evidence for the use of IVIg in severe invasive GAS disease is limited, we feel that on reviewing the available literature its use in this case was justified. The limited worldwide supply and high costs, together with a limited evidence base, warrant restricting its use to cases in which conventional therapy has failed. The literature for use of intravenous immunoglobulin in invasive GAS infection will be reviewed in this article.

PDF Share
  1. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med 1996;335:547-54.
  2. The Epidemiology of Invasive Group A Streptococcal Infections and Potential Vaccine Implications, United States, 2000-2004. Clin Infect Dis 2007;45:853-62.
  3. V. immunoglobulin therapy for infectious diseases. Drug Ther Bull 2010;48:57-60.
  4. The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic shock-like syndrome: a retrospective population-based study. JAMA 1993;269:384-9.
  5. CSTE Position Statement Number: 09-ID-60. Centers for Disease Control and Prevention. Available from: [Last accessed as on 2011 Aug 9].
  6. Evidence for the use of intravenous immunoglobulins- a review of the literature. Clin Rev Allergy Immunol 2010;38:201-69.
  7. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: A European randomised, double-blind, placebo-controlled trial. Clin Infect Dis 2003;37:333-40.
  8. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome- a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis 1999;28:800-7.
  9. Intravenous immunoglobulin in children with streptococcal toxic shock syndrome. Clin Infect Dis 2009;49:1369-76.
  10. Clinical Guidelines for Immunoglobulin Use. Department of Health Clinical guidelines for Immunoglobulin use, United Kingdom (DHUK), 2 nd ed. May 30;2008
  11. Meta-analysis: intravenous immunoglobulin in critically ill adult patients with sepsis. Ann Intern Med 2007;146:193-203
  12. Polyclonal intravenous immunoglobulin for the treatment of severe sepsis and septic shock in critically ill adults: A systematic review and meta-analysis. Crit Care Med 2007;35:2686-92.
  13. Use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septic shock. Crit Care Med 2007;35:2677-85.
  14. Score-based immunoglobulin G therapy of patients with sepsis: The SBITS study. Crit Care Med 2007;35:2693-701.
  15. Intravenous immunoglobulin for treating sepsis and septic shock. Cochrane Database Syst Rev 2002;1:CD001090. [Last assessed as on 2010 Jan 3].
  16. Cost-effectiveness of immunoglobulin M-enriched immunoglobulin (Pentaglobulin) in the treatment of severe sepsis and septic shock. J Crit Care 2005;20:239-50.
  17. Immunoglobulins in sepsis. Advances in Sepsis 2007;6:41-6.
  18. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 [published correction appears in Crit Care Med 2008;36:1394-6.
  19. IgM-enriched Immunoglobulins in Sepsis. (Chapter). Intensive Care Medicine Annual Update 2009. Vincent JL: Editor. Springer-Verlag New York. Section III. P.102-110, DOI: 10.1007/978-0-387-92278-2_10
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.