Staphylococcal tracheitis and toxic shock syndrome in a young child

[Staphylococcal tracheitis and toxic shock syndrome in a child]

Bacterial tracheitis should be raised as a possible cause in cases of severe febrile dyspnea. It can be life-threatening due to airway obstruction or, less frequently, due to toxic shock syndrome. We report the observation of toxic shock syndrome-complicated bacterial tracheitis in a 14-year-old boy. We describe the signs and symptoms of these conditions as well as the principles of treatment.

Toxic shock syndrome in children: epidemiology, pathogenesis, and management

Toxic shock syndrome (TSS) is an acute, toxin-mediated illness, like endotoxic shock, and is characterized by fever, rash, hypotension, multiorgan involvement, and desquamation. TSS reflects the most severe form of the disease caused by Staphylococcus aureus and Streptococcus pyogenes. A case definition for staphylococcal TSS was well established in the early 1980s and helped in defining the epidemiology. Since the late 1980s, a resurgence of highly invasive streptococcal infections, including a toxic shock-like syndrome, was noted worldwide and a consensus case definition for streptococcal TSS was subsequently proposed in 1993. Both TSS and the toxic shock-like syndrome occur at a lower incidence in children than in adults. Changes in the manufacturing and use of tampons led to a decline in staphylococcal TSS over the past decade, while the incidence of nonmenstrual staphylococcal TSS increased. Nonmenstrual TSS and menstrual TSS are now reported with almost equal frequency. The incidence of streptococcal TSS remains constant after its resurgence, but varies with geographic location. Streptococcal TSS occurs most commonly following varicella or during the use of NSAIDs. Sites of infection in streptococcal TSS are much deeper than in staphylococcal TSS, such as infection caused by blunt trauma, and necrotizing fasciitis. Bacteremia is more common in streptococcal TSS than in staphylococcal TSS. Mortality associated with streptococcal TSS is 5-10% in children, much lower than in adults (30-80%), and is 3-5% for staphylococcal TSS in children.TSS is thought to be a superantigen-mediated disease. Toxins produced by staphylococci and streptococci act as superantigens that can activate the immune system by bypassing the usual antigen-mediated immune-response sequence. The host-pathogen interaction, virulence factors, and the absence or presence of host immunity determines the epidemiology, clinical syndrome, and outcome. Early recognition of this disease is important, because the clinical course is fulminant and the outcome depends on the prompt institution of therapy. Management of a child with TSS includes hemodynamic stabilization and appropriate antimicrobial therapy to eradicate the bacteria. Supportive therapy, aggressive fluid resuscitation, and vasopressors remain the main elements. An adjuvant therapeutic strategy may include agents that can block superantigens, such as intravenous immunoglobulin that contains superantigen neutralizing antibodies.

Recurrent nonmenstrual toxic shock syndrome: clinical manifestations, diagnosis, and treatment

We report 3 cases of recurrent nonmenstrual toxic shock syndrome (TSS) and review the clinical manifestations, diagnosis, and treatment. The primary sites of infection were the genital tract (in a patient who underwent cesarean delivery), the upper respiratory tract, and a breast abscess. In all 3 patients, the initial illness was not recognized to be TSS; only after development of recurrent illness with desquamation was this diagnosis entertained. Strains of Staphylococcus aureus that were isolated from 2 patients produced TSS toxin-1, whereas the third strain produced staphylococcal enterotoxin B. All 3 patients lacked antibody to the implicated toxins at the time of presentation with recurrent illness. Nonmenstrual TSS can occur in a variety of clinical settings and may be recurrent. The presence of desquamation during a febrile, multisystem illness could suggest this diagnosis and should prompt the clinician to obtain appropriate cultures for S. aureus.

Airway endoscopy in the diagnosis and treatment of bacterial tracheitis in children

Children with bacterial tracheitis present with the symptoms of viral laryngotracheobronchitis or epiglottitis, but do not respond to appropriate therapy for these diseases and frequently develop acute respiratory decompensation. Since the treatment and outcome of bacterial tracheitis differ so much from those of viral laryngotracheobronchitis and epiglottitis, prompt and accurate diagnosis is essential. The aim of this study was to evaluate the significance of different diagnostic characteristics in a group of eleven patients and to compare the results to those recently reported in the pediatric and otorhinolaryngologic literature. The present study suggests that reliable predictive factors do not exist for bacterial tracheitis. No single clinical, radiological or laboratory feature was a reliable diagnostic predictor for bacterial tracheitis, nor was it any combination of these features. The only diagnostic procedure to distinguish bacterial tracheitis accurately and promptly from other forms of acute obstructive upper airway diseases was direct laryngo-tracheo-bronchoscopy. Following endoscopic removal of all tracheal secretions and pulmonary toilet, nasotracheal intubation provides sufficient airway maintenance and obviates the need for tracheostomy. Endoscopy is thus diagnostic and therapeutic at the same time. If bacterial tracheitis is suspected a direct laryngoscopy and rigid tracheobronchoscopy should be performed under general anesthesia, as prompt diagnosis and adequate treatment are essential to survival. The cultures of the purulent tracheal secretions frequently revealed Staphylococcus aureus in combination with various pathogens, particularly the involvement of Pseudomonas aeruginosa was noted in two patients. Our data imply a susceptibility of children with Down's syndrome or immunodeficiency to bacterial tracheitis.

The old and new of acute laryngotracheal infections

Laryngotracheal infections in childhood frequently result in airway obstruction, the major symptom of which is stridor. The primary aims of management are to establish a diagnosis rapidly and to maintain or secure the child's airway. Medical treatment and airway stabilization measures vary for the three most prevalent laryngotracheal infections--supraglottitis, laryngotracheitis, and bacterial tracheitis--as well as for older and newer infectious airway entities.

Childhood exanthems. Old and new

Exanthems are a common cause of rashes in children. Several recent developments have sparked a renewed interest in this group of diseases, including the identification of parvovirus B19 and human herpesvirus 6 as the causative agents of erythema infectiosum and roseola infantum. The resurgence of measles as a childhood exanthem has caused a re-examination of current immunization practices. The most common and clinically significant exanthems are discussed, with an emphasis on new findings, origins, clinical manifestations, differential diagnosis, and management.

The need for intubation in serious upper respiratory tract infection in pediatric patients (a retrospective study)

Serious bacterial infections occurred in ten children (1.4%) of 710 patients with croup admitted to the Soroka Medical Center during the years 1983-1989. Sixty-four patients (9% of all croup patients) were admitted to the pediatric intensive care unit (PICU), and 13 of them (20%) required intubation. Bacterial infections were noted in nine of the 13 intubated patients, in none of the other 51 PICU patients who did not require intubation and in one of the 646 patients (0.2%) who were not admitted to the PICU (p less than 0.0001). There was no difference in age, ethnic origin, or body temperature on arrival between the two PICU groups. Causative microorganisms were isolated from blood samples (three cases) and tracheal pus (eight cases). All intubated PICU patients were seriously ill: eight had bacterial tracheitis and one supraglottitis. Patients with bacterial tracheitis required frequent suctioning of the trachea for copious purulent secretions. The single patient with bacterial infection who was not admitted to the PICU had transient bacteremia. We conclude that the need for intubation in croup patients was an indicator for the presence of a serious bacterial infection.

Bacterial tracheitis in a young adult

A previously healthy young adult presented with inspiratory stridor and hoarseness but minimal dysphagia. Indirect laryngoscopy and lateral neck X-rays confirmed a diagnosis of membranous tracheitis. This responded to humidification, antibiotics and steroids. Secretions removed at direct laryngoscopy sent for culture grew Staphylococcus aureus. The literature is reviewed.

Low incidence of toxic shock syndrome in children with staphylococcal infection

Children have frequent staphylococcal infections, and many lack antibody to TSST-1, a toxin associated with the toxic shock syndrome (TSS). To determine why there have been no nonmenstrual cases of TSS reported in children in Utah, the authors tested S. aureus isolated from children for TSST-1 by radial immunodiffusion and sera from other hospitalized children by radioimmunoassay for antibody to TSST-1. TSST-1 was produced by 25% of S. aureus. Fifty-two children had infections with toxin producing strains. None had TSS. The prevalence of presumably protective levels of antibody (greater than or equal to 1:100) was high in newborns (80%), declined until age 2 years and then gradually increased with age. Therefore, there may have been about 20 children with toxigenic infection who lacked protective antibody but did not show the usual features of TSS. We conclude that the rarity of TSS in children is not caused by misdiagnosis, underreporting, or the absence of toxigenic strains or susceptible patients. Additional factors, such as local conditions or duration of carriage, may influence the clinical presentation of infection with TSST-1 producing staphylococci.

Bacterial croup and toxic shock syndrome

An 8-year-old boy with bacterial tracheitis, treated by endotracheal intubation, humidification, airway toilet and antibiotics, experienced a toxic shock syndrome on the day after his admission. The course was favourable. Staphylococcus aureus was isolated from tracheal secretions. Bacterial tracheitis is an infrequent cause of non-menstrual toxic shock syndrome. The diagnosis of bacterial tracheitis should be suspected in a child with toxicity and croup who is not responding to the usual therapy. Endoscopy should be performed allowing for removal of the secretions. The maintenance of a clear airway is the main purpose of the treatment.

Haemorrhagic shock and encephalopathy

Two infants are described with a fulminant disorder characterised by profound circulatory collaps and shock, generalised convulsions and unremitting coma, bleeding due to severe DIC, fever, diarrhoea, metabolic acidosis and renal and hepatic failure. Both infants died shortly after onset of the symptoms. Autopsy mainly revealed haemorrhages in different organs, anoxaemic lesions in the brain and a normal structure of liver and pancreas. No causative agent could be demonstrated. We believe that both patients suffered from haemorrhagic shock and encephalopathy, a mostly fatal disorder which has recently been described. Although the clinical and biochemical features are very distinctive, this syndrome is probably heterogeneous and its differentiation from some other disorders may be difficult. Its pathogenesis is unknown but there are some indications that intravascular activity of trypsin may play a role. During a study of the two families we obtained abnormal results of immunologic tests in most members: the interpretation of this finding remains conjectural. Haemorrhagic shock and encephalopathy may occur more frequently than the restricted literature on this subject suggests. Future studies will have to deal with the question of identity and pathogenesis.