Abstract Streptococcus pyogenes (Group A Streptococcus, GAS) is typically associated with pharyngitis and soft tissue infections. Invasive GAS (iGAS), including pneumonia, is rare but carries high mortality, even in immunocompetent individuals. It can often be seen following post-viral infection. This report describes a case of iGAS pneumonia and sepsis following parainfluenza A virus infection.A 48-year-old woman with a past medical history of hypertension presented with three days of worsening shortness of breath and productive cough with green sputum. She had sick contacts at home but denied fevers or chest pain. On arrival, she was febrile, tachycardic, tachypneic, hypoxic, and placed on BiPAP. Labs showed normal WBC count with 48% bandemia, lymphopenia, creatinine 1.5 mg/dL, lactic acid 4.3 mmol/L, and CRP 309 mg/L. Chest X-ray revealed dense left lower lobe consolidation with patchy bilateral infiltrates; CT chest confirmed multifocal airspace disease, worse in the left base and lingula. Due to worsening respiratory distress, the patient was intubated and started on vancomycin, cefepime, azithromycin, and methylprednisolone. She developed hypotension and subsequently went into shock, necessitating the need for vasopressors. Blood cultures grew S. pyogenes. A bronchoscopy with BAL was performed and revealed extensive airway inflammation. BAL fluid was also positive for GAS. Respiratory viral panel was also positive for parainfluenza A virus however negative for COVID and influenza. Antibiotics were subsequently de-escalated to ceftriaxone and linezolid. Her clinical status gradually improved with supportive care. She was successfully extubated, weaned off vasopressors and steroids, and discharged home on room air after a prolonged hospital course.GAS pneumonia is rare but aggressive and can cause multiorgan failure and streptococcal toxic shock syndrome. While uncommon in immunocompetent hosts, co-infection with respiratory viruses can predispose to life-threatening disease. Early recognition requires a high index of suspicion and aggressive treatment are crucial to improving outcomes, as mortality can reach 30-60%. The treatment of choice remains to be Penicillin, and adjunctive Clindamycin is added at times given its ability to suppress toxin production. As in our case, supportive measures, such as mechanical ventilation and vasopressors might be needed to avoid fatal outcomes. This abstract is funded by: None
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