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A young female with no identifiable risk factors developed rapid, overwhelming Staphylococcus aureus endocarditis. Despite rapid sterilization of the blood and the mitral valve with optimal antimicrobials, she had persistent septic shock. In order to investigate this, the toxin-producing capacity of the infecting strain and the patient's ability to produce antibodies were determined. The strain produced high levels of both alpha-toxin and staphylococcal enterotoxin A (SEA), whilst the patient responded with modestly high levels of antibodies to alpha-toxin and low-normal levels to SEA. The patient was most probably susceptible to the actions of SEA and developed a toxic-shock-syndrome-like disease that further aggravated her valvular dysfunction. This case illustrates that optimal antimicrobial therapy alone is not sufficient treatment in patients with persistent toxic shock and that there is a need to evaluate immunomodulatory strategies in such patients.

Role of staphylococcal enterotoxin A in a fatal case of endocarditis