A fatal case of staphylococcal toxic shock syndrome

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children: A 10-Year Single-Centre Experience from North India

OBJECTIVE

To describe the clinical and laboratory profile, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India.

METHODS

This retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011-December 2020) including children < 12 y with TSS (n = 63).

RESULTS

The median (interquartile range, IQR) age was 5 (2-9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12-17). The primary focus of infection was identified in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n = 11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fluid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n = 17). The duration of PICU and hopsital stay was 5 (4-10) and 7 (4-11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive-inotropic score.

CONCLUSION

TSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

Toxic shock syndrome: the great masquerader

Toxic shock syndrome is a rare but potentially lethal toxin-mediated illness that can be caused by streptococcal and staphylococcal species. It initially presents as a febrile illness that rapidly progresses to multiorgan dysfunction, hence a high index of suspicion coupled with rapid verification of the diagnosis and aggressive treatment is required to improve the outcome of the disease. A 23-year-old man presented with high-grade fever associated with headache, retro-orbital pain, gastroenteritis and gum bleeds. Treatment was initiated keeping in mind the possibility of dengue haemorrhagic fever. However, further clinical deterioration led us to re-examine our patient, revealing an old neglected wound. Microbiological confirmation of methicillin-resistant Staphylococcus aureus from the wound swab and prompt institution of appropriate treatment led to a favourable outcome in a case known to be associated with serious morbidity and mortality.