{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T15:51:17Z","timestamp":1782489077223,"version":"3.54.5"},"reference-count":22,"publisher":"BMJ","issue":"4","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2026,3,5]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:p>\n                    An independent, community-dwelling man in his seventies with a medical history of type 2 diabetes mellitus and atrial fibrillation presented to the emergency department with acute-onset confusion. He rapidly developed refractory shock complicated by multi-organ failure, which required multiple vasopressors for haemodynamic support and renal replacement therapy for kidney failure. The early initiation of methylene blue was associated with his rapid stabilisation and improvement. He was found to have an upper extremity wound with group A\n                    <jats:italic>Streptococcus<\/jats:italic>\n                    , leading to the diagnosis of group A\n                    <jats:italic>Streptococcus<\/jats:italic>\n                    toxic shock syndrome. We share this case to encourage consideration of toxic shock syndrome on the differential for refractory septic shock and to highlight the early use of methylene blue in a patient who recovered from shock.\n                  <\/jats:p>","DOI":"10.1136\/bcr-2025-271683","type":"journal-article","created":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T15:10:17Z","timestamp":1775229017000},"page":"e271683","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Early use of methylene blue in the management of refractory group A streptococcal toxic shock syndrome with multi-organ failure in the intensive care unit"],"prefix":"10.1136","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8948-4413","authenticated-orcid":false,"given":"Eric","family":"Steinbrook","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6557-9402","authenticated-orcid":false,"given":"Amy S","family":"Labar","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hadrian","family":"Mendoza","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section of Medical Oncology and Hematology, Yale School of Medicine, New Haven, Connecticut, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Ghincea","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,4,3]]},"reference":[{"key":"2026062608152995000_19.4.e271683.1","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(09)70066-0"},{"key":"2026062608152995000_19.4.e271683.2","doi-asserted-by":"crossref","first-page":"1498","DOI":"10.1001\/jama.2025.0910","article-title":"Invasive Group A Streptococcal Infections in 10 US States","volume":"333","author":"Gregory","year":"2025","journal-title":"JAMA"},{"key":"2026062608152995000_19.4.e271683.3","doi-asserted-by":"publisher","DOI":"10.1128\/JCM.00422-08"},{"key":"2026062608152995000_19.4.e271683.4","doi-asserted-by":"publisher","DOI":"10.1007\/S00134-021-06506-Y"},{"key":"2026062608152995000_19.4.e271683.5","doi-asserted-by":"publisher","DOI":"10.1186\/s13054-023-04397-7"},{"key":"2026062608152995000_19.4.e271683.6","doi-asserted-by":"crossref","DOI":"10.3389\/fmed.2024.1431321","article-title":"Methylene blue therapy in addition to standard treatment for acute-phase septic shock: a pilot randomized controlled trial","volume":"11","author":"Luis-Silva","year":"2024","journal-title":"Front Med (Lausanne)"},{"key":"2026062608152995000_19.4.e271683.7","article-title":"Methylene Blue in Septic Shock: A Systematic Review and Meta-Analysis","volume":"6","author":"Fernando","year":"2024","journal-title":"Crit Care Explor"},{"key":"2026062608152995000_19.4.e271683.8","doi-asserted-by":"crossref","DOI":"10.3389\/fmed.2024.1366062","article-title":"Methylene blue in sepsis and septic shock: a systematic review and meta-analysis","volume":"11","author":"Ballarin","year":"2024","journal-title":"Front Med (Lausanne)"},{"key":"2026062608152995000_19.4.e271683.9","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1177\/08850666241300312","article-title":"Methylene Blue for Septic Shock: A Systematic Review and Meta-analysis of Randomized and Prospective Observational Studies","volume":"41","author":"Alkazemi","year":"2026","journal-title":"J Intensive Care Med"},{"key":"2026062608152995000_19.4.e271683.10","doi-asserted-by":"publisher","DOI":"10.1001\/jama.1993.03500030088038"},{"key":"2026062608152995000_19.4.e271683.11","doi-asserted-by":"crossref","first-page":"764","DOI":"10.1055\/s-0034-1382854","article-title":"Fulminant Puerperal Sepsis caused by Hemolytic Group A Streptococci and Toxic Shock Syndrome - A Case Report and Review of the Literature","volume":"74","author":"Bauerschmitz","year":"2014","journal-title":"Geburtshilfe Frauenheilkd"},{"key":"2026062608152995000_19.4.e271683.12","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciu444"},{"key":"2026062608152995000_19.4.e271683.13","article-title":"Clinical Efficacy of Intravenous Immunoglobulins in Management of Toxic Shock Syndrome: An Updated Literature Review","volume":"13","author":"Amreen","year":"2021","journal-title":"Cureus"},{"key":"2026062608152995000_19.4.e271683.14","unstructured":"World Health Organization . The selection and use of essential medicines, 2025: WHO model list of essential medicines, 24th list. Geneva World Health Organization; 2025."},{"key":"2026062608152995000_19.4.e271683.15","doi-asserted-by":"crossref","first-page":"630","DOI":"10.1186\/s13063-024-08439-5","article-title":"Efficacy of methylene blue in refractory septic shock: study protocol for a multicenter, randomized, placebo-controlled trial","volume":"25","author":"Jia","year":"2024","journal-title":"Trials"},{"key":"2026062608152995000_19.4.e271683.16","doi-asserted-by":"publisher","DOI":"10.1016\/0006-2952(93)90072-5"},{"key":"2026062608152995000_19.4.e271683.17","doi-asserted-by":"publisher","DOI":"10.1164\/ajrccm.161.6.9812004"},{"key":"2026062608152995000_19.4.e271683.18","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1016\/j.amjms.2020.06.007","article-title":"The Story of Nitric Oxide, Sepsis and Methylene Blue: A Comprehensive Pathophysiologic Review","volume":"360","author":"Saha","year":"2020","journal-title":"Am J Med Sci"},{"key":"2026062608152995000_19.4.e271683.19","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1186\/s12871-024-02792-3","article-title":"Comparative study between high and low dose methylene blue infusion in septic cancer patients: a randomized, blinded, controlled study","volume":"25","author":"Shaker","year":"2025","journal-title":"BMC Anesthesiol"},{"key":"2026062608152995000_19.4.e271683.20","doi-asserted-by":"publisher","DOI":"10.1007\/BF01706481"},{"key":"2026062608152995000_19.4.e271683.21","first-page":"455","article-title":"Methylene Blue as an Adjunct to Treat Vasoplegia in Patients Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass: A Literature Review","volume":"86","author":"Arevalo","year":"2018","journal-title":"AANA J"},{"key":"2026062608152995000_19.4.e271683.22","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2025.02.018"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2025-271683","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T15:21:26Z","timestamp":1782487286000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2025-271683"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":22,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,4,3]]},"published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1136\/bcr-2025-271683"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2025-271683","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]}}}