Use of the Seraph 100 Dialysis Filter in a Patient with Toxic Shock Syndrome from Streptococcus pyogenes Bacteremia

Introduction: The Seraph 100 Microbind Affinity Blood Filter (Seraph 100) is a hemoperfusion dialysis filter which employs pathogen adsorption therapy using heparin-coated polyethylene beads. Data exists supporting its effectiveness among COVID-19 patients where the filter was allowed under emergency use authorization by the FDA. It has been shown to bind various pathogens (with affinity for streptococcus pyogenes (GAS)), endotoxins and cytokines, allowing their removal from the bloodstream. Case Description: A 26 year-old female who gave birth four days prior was admitted to the intensive care unit with high fevers and septic shock requiring 3 vasopressors causing severe lactic acidosis (to 11.6 mmol/L). For GAS bacteremia causing toxic shock syndrome (TSS) she received meropenem, clindamycin, and vancomycin. She suffered necrosis of her nose, fingers and toes as well as disseminated intravascular coagulation (DIC). She also suffered anuric renal failure requiring continuous renal replacement therapy (CRRT). Five days into hospitalization, despite emergent hysterectomy for source control, intravenous hydroxycobalamin, and methylene blue, she still required 3 vasopressors for persistent shock. The Seraph 100 filter was obtained and was installed in series with an M100 filter in a PrismaFlex dialysis machine. The day after installation, her shock completely resolved, then enabling fluid removal with CRRT and initiation of feeding. With shock resolved, her necrotic lesions showed some improvement and did not auto-amputate. Additionally, her DIC improved which enabled her to be treated with heparin for thrombi in distal extremities. Each night, clotting of the Seraph 100 filter would require its replacement the following day; in total 8 filters were used. Discussion: This case demonstrates use of the Seraph 100 filter in a patient suffering from persistent GAS-related TSS after source control. By improving rapidly she avoided further complications of shock, including worsening of necrosis which may be attributed to vasopressor induced acute limb ischemia, as well as improved ultrafiltration enabling weaning off mechanical ventilation. No clear adverse events were attributed to use of this filter. Given the high mortality rate associated with TSS, future studies should evaluate for this filter’s efficacy in improving outcomes for such patients.