Bacterial Superantigen-Mediated Toxic Shock: Hyperinflammatory Trajectories and Extracorporeal Immunomodulation in Streptococcal Toxic Shock Syndrome.

Streptococcal toxic shock syndrome (STSS) is a fulminant manifestation of invasive group A Streptococcus infection characterized by superantigen-driven hyperinflammation, refractory shock, and rapidly progressive multiorgan dysfunction. Despite antimicrobial therapy, source control, intravenous immunoglobulin, and intensive organ support, some patients deteriorate rapidly, prompting interest in extracorporeal immunomodulation. This narrative review examines the biological rationale and clinical experience of hemoadsorption in STSS, supported by an illustrative case and comparison with published reports. Our patient developed vasopressor-dependent shock, acute kidney injury, thrombocytopenia, hepatic and myocardial injury, hyperlactatemia, and metabolic acidosis within 48 h. CytoSorb was integrated with continuous venovenous hemofiltration during ongoing deterioration, followed by hemodynamic and organ recovery; however, concurrent therapies preclude attribution of benefit to hemoadsorption. Published cases show a similar pattern, with extracorporeal escalation initiated during refractory shock and accumulating organ dysfunction rather than at a predefined biomarker threshold. Although experimental and observational evidence supports the biological activity of hemoadsorption, clinical evidence remains insufficient to establish a survival benefit. Current evidence does not support routine hemoadsorption for STSS. A rapidly progressive, multidimensional hyperinflammatory trajectory may instead provide a framework for future studies of patient selection and treatment timing.