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

Mortality risk factors and fulminant sub-phenotype in anaerobic bacteremia: a 10-year retrospective, multicenter, observational cohort study

PURPOSE

During the last decade, the incidence of anaerobic bacteremia (AB) has been increasing. Patients with AB may develop complex underlying diseases, which can occasionally be accompanied by fatal or fulminant outcomes. However, the risk factors for AB-related mortality remain unclear. Herein, we sought to elucidate the risk factors for AB-related mortality.

METHODS

In this multicenter, retrospective, observational study, we enrolled patients with culture-proven AB from six tertiary hospitals in Japan, between January 2012 and December 2021. Data on patient and infection characteristics, laboratory findings, treatment, and outcome were collected, and their associations with mortality were analyzed.

RESULTS

A total of 520 participants were included. The 30-day mortality in the study cohort was 14.0% (73 patients), and malignant tumors were frequently observed comorbidities in 48% of the entire cohort. Multivariable logistic regression analysis showed a Charlson comorbidity score of > 6, serum creatinine level of > 1.17 mg/dL, and hypotension to be independent risk factors for 30-day mortality in AB (odds ratios [ORs] 2.12, 2.25, and 5.12, respectively; p < 0.05), whereas drainage significantly reduced this risk (OR, 0.28; p < 0.0001). Twelve patients (2.3% of the whole cohort and 16.4% of the deceased patients) presented with extremely rapid progression leading to fatal outcome, consistent with "fulminant AB."

CONCLUSIONS

This study identified acute circulatory dysfunction and performance of drainage as independent predictive factors for 30-day AB-related mortality and revealed the existence of a fulminant AB sub-phenotype. Our findings could serve as a practical guide to predict the clinical outcomes of AB.

Toxic Shock Syndrome: Eighteen Years of Experience in a Pediatric Intensive Care Unit

Introduction Toxic shock syndrome (TSS) is a life-threatening disease usually caused by a Staphylococcus aureus or group Aβ-hemolytic Streptococcus infection. Methods In this retrospective study, we included patients with TSS admitted to a tertiary hospital's pediatric intensive care unit (PICU) over the last 18 years. We compared the staphylococcal TSS (Staph-TSS) and streptococcal TSS (Strep-TSS) groups. Results We included 17 patients (64.7% male), with a median age of 6.1 years (3.0 years for streptococcal TSS versus 13.3 years for staphylococcal TSS, p = 0.040), a median of 3.0 days from symptom onset to diagnosis, and a median of 6.0 days of hospitalization. Ten patients met the Centers for Disease Control and Prevention (CDC) criteria for staphylococcal TSS (one menstrual-related) and seven met the criteria for streptococcal TSS (four of them occurring since the COVID-19 pandemic was declared). Fifteen patients had identified risk factors, primarily cutaneous lesions (29.4%). In 15 patients, at least three organs or systems were affected, with fever, rash, and hypotension as universal findings. Mucous membrane hyperemia was present in 16 patients, gastrointestinal symptoms in 14 patients, and desquamation in nine. Muscular involvement was present in seven patients, all with staphylococcal TSS (p = 0.010). All patients received two or more antibiotics, including a protein synthesis inhibitor (except for one), and required fluid resuscitation and vasoactive amines (median three days). Six patients needed invasive mechanical ventilation (median seven days). Albumin infusion was necessary in six patients, significantly more frequently in patients with streptococcal TSS (p = 0.035). Two patients with staphylococcal TSS died, while the seven patients with streptococcal TSS survived hospital discharge. There were no recurrent cases. Conclusions Our study revealed TSS severity and multiorgan involvement, emphasizing the importance of early diagnosis and intervention. Risk factors were prevalent, and we noted an increased frequency of group A streptococcal (GAS) TSS post-COVID-19 pandemic.

Cytokine Storm and Sepsis-Induced Multiple Organ Dysfunction Syndrome

There is extensive overlap of clinical features among familial or primary HLH (pHLH), reactive or secondary hemophagocytic lymphohistiocytosis (sHLH) [including macrophage activation syndrome (MAS) related to rheumatic diseases], and hyperferritinemic sepsis-induced multiple organ dysfunction syndrome (MODS); however, the distinctive pathobiology that causes hyperinflammatory process in each condition requires careful considerations for therapeutic decision-making. pHLH is defined by five or more of eight HLH-2004 criteria [1], where genetic impairment of natural killer (NK) cells or CD8+ cytolytic T cells results in interferon gamma (IFN-γ)-induced hyperinflammation regardless of triggering factors. Cytolytic treatments (e.g., etoposide) or anti-IFN-γ monoclonal antibody (emapalumab) has been effectively used to bridge the affected patients to hematopoietic stem cell transplant. Secondary forms of HLH also have normal NK cell number with decreased cytolytic function of varying degrees depending on the underlying and triggering factors. Although etoposide was uniformly used in sHLH/MAS in the past, the treatment strategy in different types of sHLH/MAS is increasingly streamlined to reflect the triggering/predisposing conditions, severity/progression, and comorbidities. Accordingly, in hyperferritinemic sepsis, the combination of hepatobiliary dysfunction (HBD) and disseminated intravascular coagulation (DIC) reflects reticuloendothelial system dysfunction and defines sepsis-associated MAS. It is demonstrated that as the innate immune response to infectious organism prolongs, it results in reduction in T cells and NK cells with subsequent lymphopenia even though normal cytolytic activity continues (Figs. 30.1, 30.2, 30.3, and 30.4). These changes allow free hemoglobin and pathogens to stimulate inflammasome activation in the absence of interferon-γ (IFN-γ) production that often responds to source control, intravenous immunoglobulin (IVIg), plasma exchange, and interleukin 1 receptor antagonist (IL-1Ra), similar to non-EBV, infection-induced HLH.

Streptococcal toxic shock syndrome with associated necrotising fasciitis necessitating amputation of the lower extremity - A case report

Streptococcal toxic shock syndrome is a severe, invasive and life-threatening infection associated with a high risk of rapid multiorgan failure. It is associated with high morbidity and mortality. Streptococcal toxic shock syndrome is very commonly caused by group A-Streptococcus pyogenes, ß-haemolytic streptococcus, a typical human-specific gram-positive bacterial pathogen. We present here the case report of a 54-year-old man with a rapidly progressive streptococcal toxic shock syndrome due to necrotising fasciitis of the left lower limb and describe the successful treatment through close interdisciplinary care.

Applications of microbiology to different forensic scenarios - A narrative review

In contrast to other forensic disciplines, forensic microbiology is still too often considered a "side activity" and is not able to make a real and concrete contribution to forensic investigations. Indeed, the various application aspects of this discipline still remain a niche activity and, as a result, microbiological investigations are often omitted or only approximated, in part due to poor report in the literature. However, in certain situations, forensic microbiology can prove to be extremely effective, if not crucial, when all other disciplines fail. Precisely because microorganisms can represent forensic evidence, in this narrative review all the major pathological forensic applications described in the literature have been presented. The goal of our review is to highlight the versatility and transversality of microbiology in forensic science and to provide a comprehensive source of literature to refer to when needed.

Toxic Shock Syndrome Secondary to Erythroderma: Unraveling the Underlying Triggers

Toxic shock syndrome (TSS) is a rare and life-threatening condition characterized by the systemic manifestation of severe infection. It is caused by exotoxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes. Erythroderma, often described as generalized exfoliative dermatitis, is a rare and severe dermatological condition involving more than 90% of the body surface, identified as an uncommon cause of TSS. Here, we describe a case of a 72-year-old male who presented with signs and symptoms of erythroderma presenting as extensive erythematous scaling and lichenified plaques on multiple body surfaces and later developed TSS.

The SEB1741 Aptamer Is an Efficient Tool for Blocking CD4+ T Cell Activation Induced by Staphylococcal Enterotoxin B

Staphylococcal enterotoxin B (SEB) is a protein produced by Staphylococcus aureus, which is toxic to humans. It is well known for its ability to stimulate the exacerbated activation of proinflammatory CD4+ T cells (Th1 profile), and in vitro studies have been conducted to understand its mechanism of action and its potential use as an immune therapy. However, the efficiency of the SEB1741 aptamer in blocking SEB has not been experimentally demonstrated.

METHODS

Enrichment CD4+ T cells were stimulated with SEB, and as a blocker, we used the SEB1741 aptamer, which was previously synthesised by an "in silico" analysis, showing high affinity and specificity to SEB. The efficiency of the SEB1741 aptamer in blocking CD4+ T cell activation was compared with that of an anti-SEB monoclonal antibody. Flow cytometry and Bio-Plex were used to evaluate the T-cell function.

RESULTS

In vitro, SEB induced the activation of CD4+ T cells and favoured a Th1 profile; however, the SEB1741 aptamer was highly efficient in decreasing the frequency of CD4+ T cells positive to ki-67 and CD69 cells, this means that proliferation and activation of CD4+ T cells was decreased. Moreover, the production of interleukin 2 (IL-2) and interferon-gamma (IFN-γ) was affected, suggesting that the Th1 profile is not present when the SEB1441 aptamer is used. Thus, the SEB1741 function was similar to that of anti-SEB.

CONCLUSIONS

The SEB1741 aptamer is a valuable tool for blocking CD4+ T cell activation and the subsequent release of proinflammatory cytokines by SEB stimulation.

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.

Comparison of Characteristics and Outcomes of Multisystem Inflammatory Syndrome, Kawasaki Disease and Toxic Shock Syndrome in Children

Background and Objectives: Since the first cases of multisystem inflammatory syndrome in children (MIS-C) in April 2020, the diagnostic challenge has been to recognize this syndrome and to differentiate it from other clinically similar pathologies such as Kawasaki disease (KD) and toxic shock syndrome (TSS). Our objective is to compare clinical signs, laboratory data and instrumental investigations between patients with MIS-C, KD and TSS. Materials and Methods: This retrospective observational study was conducted at the Children's Clinical University Hospital, Latvia (CCUH). We collected data from all pediatric patients <18 years of age, who met the Centers for Disease Control and Prevention case definition for MIS-C, and who presented to CCUH between December 2020 and December 2021. We also retrospectively reviewed data from inpatient medical records of patients <18 years of age diagnosed as having KD and TSS at CCUH between December 2015 and December 2021. Results: In total, 81 patients were included in this study: 39 (48.1%) with KD, 29 (35.8%) with MIS-C and 13 (16.1%) with TSS. In comparison with TSS and KD, patients with MIS-C more often presented with gastrointestinal symptoms (abdominal pain (p < 0.001), diarrhea (p = 0.003)), shortness of breath (p < 0.02) and headache (p < 0.003). All MIS-C patients had cardiovascular involvement and 93.1% of MIS-C patients fulfilled KD criteria, showing higher prevalence than in other research. Patients with KD had higher prevalence of cervical lymphadenopathy (p < 0.006) and arthralgias (p < 0.001). In comparison with KD and TSS, MIS-C patients had higher levels of ferritin (p < 0.001), fibrinogen (p = 0.04) and cardiac biomarkers, but lower levels of platelets and lymphocytes (p < 0.001). KD patients tended to have lower peak C-reactive protein (CRP) (p < 0.001), but higher levels of platelets. Acute kidney injury was more often observed in TSS patients (p = 0.01). Pathological changes in electrocardiography (ECG) and echocardiography were significantly more often observed in MIS-C patients (p < 0.001). Conclusions: This research shows that MIS-C, KD and TSS have several clinical similarities and additional investigations are required for reaching final diagnosis. All the patients with suspected MIS-C diagnosis should be examined for possible cardiovascular involvement including cardiac biomarkers, ECG and echocardiography.

Staphylococcal Toxic Shock Syndrome in a Burned Child Treated with an Antimicrobial Foam Dressing: A Case Report

Staphylococcal toxic shock syndrome (TSS) is a severe systemic disease characterized by fever, hypotension, desquamating rash, and multiorgan dysfunction. Attributed to bacterial exotoxins, TSS has been a known, though rare, complication in the field of pediatric burns for decades. The adoption of new antimicrobial burn dressings has allowed for the management of small to medium sized burns with minimal discomfort or inconvenience to the patient. In this report, we discuss a 3-year-old male with burns wounds dressed using a silver-impregnated foam who went on to develop TSS.

MIS-C related to SARS-CoV-2 infection: a narrative review of presentation, differential diagnosis, and management

Multisystem Inflammatory Syndrome in Children (MIS-C), a rare condition, has been reported approximately 2-4 weeks after the onset of COVID-19 in children and adolescents, causing inflammation in multiple systems, including cardiovascular and respiratory, digestive, and central nervous systems. This condition is also known as hyperinflammatory shock, Kawasaki-like disease, and Pediatric Inflammatory Multisystem Syndrome (PIMS). The signs and symptoms include but are not limited to fever, rash, peripheral edema, gastrointestinal symptoms, conjunctivitis, and shock. Thirty-eight studies met our criteria, with a total of 5822 patients. The most affected population was between 5-18 years of age. We noted that MIS-C presented with a wide range of signs and symptoms that overlap with Kawasaki Disease, including high fever, sore throat, malaise, tachypnea, tachycardia, conjunctival injection, mucosal edema, cardiac involvement, and gastrointestinal symptoms. It causes an increase in IL-17A, IL-6, and arterial damage, a distinct difference from Kawasaki disease. The laboratory findings in MIS-C showed an increase in inflammatory markers like CRP, ESR, ferritin, leukocytes, and TNF-α. WHO stated that 23% of affected children with MIS-C had underlying conditions like chronic lung diseases, cardiovascular disease, and immunosuppression. In most affected children, aspirin and IVIG were successful, which resulted in a decrease in the inflammatory markers. We find that MIS-C is a rare, but potentially fatal pediatric complication, after COVID-19 infection. The aim of this article is to study the emerging relationship between COVID-19 and MIS-C in children and adolescents affected by this condition, to discuss the immunological mechanisms, and explore potential therapies.

A Rare Case of Staphylococcal Toxic Shock Syndrome in a Neonate

Staphylococcus toxic shock syndrome (TSS) is not well described in neonates. The present criteria for diagnosis of TSS have not yet been validated in neonates. Here, we present a case of a 13-day-old female baby who presented with acute kidney injury (AKI). She had a pus-draining lesion on the head, and the pus grew Staphylococcus aureus. Based on the clinical criteria of fever, desquamation, hypotension, and AKI and laboratory criteria of absence of growth of any organisms in blood and cerebrospinal fluid, we diagnosed the case as TSS. She was treated with antibiotics, oxygen, and fluids, along with inotropic support and mechanical ventilation, and she recovered fully and was discharged on day 17 of admission. As there is no single test to diagnose TSS and it is uncommon in neonates, physicians should be familiar with the clinical presentation of the disease to make early diagnosis.

Multisystem Inflammatory Syndrome in Children: A Case Report From Japan

This study reports a case of multisystem inflammatory syndrome in children (MIS-C). Although MIS-C is currently not widespread in Japan, it is important to consider this syndrome, particularly when the patient is younger than 21 years and presents with fever and shock symptoms associated with COVID-19. According to the latest statistics updated by the Centers for Disease Control and Prevention in early 2021, the total number of MIS-C patients is only 1659 and there have been no reports from Japan. Therefore, information to accurately diagnose MIS-C is needed. This study is the first case report of MIS-C in Japan, and it proposes information to identify this serious syndrome.

Streptococcal Toxic Shock Syndrome in a Child With Venous Malformation

We report the case of a child with a venous malformation (VM), in whom streptococcal toxic shock syndrome (STSS) developed from cellulitis. A six-year-old boy with VM of the left lower limb had a fever and left lower limb pain since the afternoon of the day before admission. He presented with swelling, redness, heat, and tenderness on an area extending from the sole of the foot to the lower leg on the left side. Disturbance of consciousness gradually appeared, and he was admitted to the intensive care unit. We administered intravenous antibiotics and an immunoglobulin. On day two of hospitalization, group A hemolytic streptococci were detected in the blood culture. We managed the patient in coordination with a plastic surgeon for consideration of surgical interventions. The local findings subsequently improved to change the antibiotics promptly without debridement, and he was discharged after 14 days of antibiotic therapy. In this case, the VM may have contributed to the worsening of the infection. In children with VM, soft tissue inflammation with local pain and fever must be treated promptly, with the expectation of prompt surgical intervention, because the condition can progress to sepsis and necrotizing fasciitis.

Management skin manifestation of multisystem inflammatory syndrome associated with SARS-CoV-2

BACKGROUND

Multisystem inflammatory syndrome (MIS), which develops after a past covid-19 infection. MIS can be described in different tissue inflammation, including the heart, lung, kidney, brain, skin, eye, and or gastrointestinal organs at the presence of COVID-19. Initially, MIS was described in Europe in children infected with SARS-CoV-2, then it was recently seen in the USA in 2020. MIS is a rare but serious disease condition associated with COVID-19 that can affect children (MIS-C) and adults (MIS-A).

CASE PRESENTATION

A 44-year-old male who showed MIS-A in 59-day after his first covid-19 contact history. The patient presented to our emergency department with complaints of high fever, nausea, weakness, redness of the eyes, headache, and joint pain. On the second day of his hospitalization, a maculopapular skin lesion was seen in most of the skin. His fever could not be controlled even given paracetamol and broad effective antibiotics. His clinical, radiological, and laboratory findings showed that he had MIS-A. The patient was given intravenous pulse methylprednisolone and intravenous immunoglobulin (IVIG). These treatments, then, resulted in improvement of his clinical conditions, including fever and skin lesions, on the second day of the treatment. The patient was discharged in 14 days after the treatment.

CONCLUSION

This report indicated that diagnosis and treatment of MIS-A could result in reducing patient morbidity and mortality.

Antimicrobial Therapy in Pediatric Sepsis: What Is the Best Strategy?

Pediatric sepsis is a relevant cause of morbidity and mortality in this age group. Children are affected differently in high and low-income countries. Antibiotics are crucial for the treatment of sepsis, but indiscriminate use can increase resistance worldwide. The choice of a correct empiric therapy takes into consideration the site of infection, local epidemiology, host comorbidities and recent antibiotic exposure. Antibiotics should be administered in the first hour for patients with septic shock, and always intravenously or via intraosseous access. Culture results and clinical improvement will guide de-escalation and length of treatment. New diagnostic methods can help improve the prescription of adequate treatment. Prevention of sepsis includes vaccination and prevention of healthcare-associated infections. More research and education for awareness of sepsis is needed to improve care.

Austere Foreign Body Injuries in Children and Adolescents: A Characterization of Penile, Rectal, and Vaginal Injuries Presenting to Emergency Departments in the United States From 2008 to 2017

BACKGROUND

Pediatric foreign body (FB) injuries to the nasal, aural, and/or oral cavities are well documented. Description of austere foreign body (AFB) injuries involving the rectum, vagina, or penis eludes the current pediatric literature. Austere FBs can be difficult to identify and have the potential to cause serious consequences. We aim to characterize AFB injuries by children and adolescents presenting to emergency departments (EDs) in the United States.

METHODS

The National Electronic Injury Surveillance System was queried to include subjects aged 0 to 25 years using a primary search term for diagnosis of foreign body from the period of January 2008 to January 2017. The consumer product and the body part involved (ie, rectal, vaginal, penile) were analyzed. Taylor series linearization generated national estimates. A trend analysis was performed using the Cochrane Armitage test of trend.

RESULTS

There were 27,755 (95% confidence interval, 21,170-34,338) national estimated childhood ED visits for suspected AFB injuries during 2008 to 2017 including an estimated 7756 vaginal FBs, 7138 penile FBs, and 8359 rectal FBs (RFBs). Over the timeline, there was a significant up trend in the frequency of annual RFBs (P < 0.01).

CONCLUSION

Austere FB injuries appear to cluster around age of 7 years. Most AFB injuries are able to be treated and released from the ED. It appears that RFB injury frequencies are rising and tend to require more frequent admission. Providers must be vigilant in the diagnosis and management of these potentially hazardous injury types.

Post-surgical staphylococcal toxic shock syndrome in pediatrics: A case report

Introduction

Toxic shock syndrome (TSS) is a rare but serious, life-threatening medical condition and potentially lethal if not detected and treated early. It is mainly caused by a toxin called toxin-1 produced by Staphylococcus aureus, and characterized by fever, hypotension, rash, skin desquamation and multisystem involvement.

Case presentation

Herein, we describe a nine-month-old male patient who presented to the hospital complaining of fever, vomiting and hypoactivity on day one post-orchidopexy. During hospitalization, his condition began to deteriorate with signs and symptoms of multisystemic failure. Laboratory tests and radiological images were done, leading to the decision to reopen and drain the surgical wound. Wound and nasal swabs were cultured and showed S. aureus infection, and the diagnosis of toxic shock syndrome was confirmed.

Discussion

TSS is a systemic illness resulting from overwhelming host response to bacterial exotoxins, that cause T cells activation and the release of pro-inflammatory cytokines (IL-1 and TNF-α causing fever, hypotension, and tissue injury). Also, it can present with CNS signs that may be misdiagnosed with meningitis in pediatrics.

It requires early identification and treatment despite its rarity with mortality rate of 81% even with treatment.

The patient's presentation, examination and laboratories tests with the blood and wound cultures were highly suggestive for this condition.

Conclusion

Physicians must maintain a high index of suspicion for TSS, as early diagnosis and treatment make a difference. This condition shouldn't be excluded even in young age patients or after simple procedure as in our case in which TSS occurred after orchidopexy.

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Toxic shock syndrome is a life-threatening condition that can be highly mortal even with treatment.

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Post-surgical TSS is very rare and according to the literature this is the first reported case post-orchidopexy.

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Broad spectrum antibiotics with debridement of the necrotic tissue as management are the best option to treat this condition.

Cardiac involvement in a child post COVID-19: a case from Lebanon

We report on an 8-year-old boy, who presented to the emergency department at our institution with fever, generalised oedema and hypotension. Investigations revealed anaemia, thrombocytopenia in addition to elevated serum inflammatory markers, a negative COVID-19 PCR test and a positive COVID-19 IgG. His echocardiography was consistent with carditis in otherwise morphologically normal heart with depressed cardiac function, moderate-to-severe mitral valve regurgitation, moderate tricuspid regurgitation with an estimated right ventricular systolic pressure half systemic, trace aortic regurgitation, bilateral small pleural effusions, distended inferior vena cava and normal coronaries. He was started on inotropic support, intravenous immunoglobulin and methylprednisolone, and was transferred to the paediatric intensive care unit. To the best of our knowledge, this was the first case of multisystem inflammatory syndrome in children encountered in Lebanon. The presentation and management were thoroughly described in this article aiming to share our experience and to contribute to the rapidly emerging literature on this syndrome.

Multisystem inflammatory syndrome (MIS-C) in Pakistani children: A description of the phenotypes and comparison with historical cohorts of children with Kawasaki disease and myocarditis

OBJECTIVES

To determine clinical, laboratory features and outcomes of Multisystem Inflammatory Syndrome in children (MIS-C) and its comparison with historic Kawasaki Disease (KD) and Viral Myocarditis (VM) cohorts.

METHODS

All children (1 month- 18 years) who fulfilled the World Health Organization criteria of MIS-C presenting to two tertiary care centers in Karachi from May 2020 till August 31st were included. KD and VM admitted to one of the study centers in the last five years prior to this pandemic, was compared to MIS-C.

RESULTS

Thirty children with median age of 24 (interquartile range (IQR)1-192) months met the criteria for MIS-C. Three phenotypes were identified, 12 patients (40%) with KD, ten (33%) VM and eight (26%) had features of TSS. Echocardiography showed coronary involvement in 10 (33%), and moderate to severe Left Ventricular dysfunction in 10 (33%) patients. Steroids and intravenous immunoglobulins (IVIG) were administered to 24 (80%) and 12 (41%) patients respectively while 7 (23%) received both. Overall, 20% children expired. During the last five years, 30 and 47 children were diagnosed with KD and VM, respectively. Their comparison with MIS-C group showed lymphopenia, thrombocytosis, and higher CRP as well as more frequent atypical presentation in MIS-C KD group with less coronary involvement. The MIS-C VM was more likely to present with fulminant myocarditis.

CONCLUSIONS

Our MIS-C cohort is younger with higher mortality compared to previous reports. MIS-C is distinct from historic cohorts of KD and VM in both in clinical features and outcomes.

Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010-20171

Data are limited on the incidence and management of streptococcal toxic shock syndrome (TSS) and nonstreptococcal TSS in children. We aimed to define the clinical patterns of TSS at Nationwide Children's Hospital in Ohio as they relate to published criteria, diagnostic decisions, and treatment options. Through retrospective chart reviews, we identified 58 patients with TSS (27 streptococcal, 31 nonstreptococcal) during January 2010-September 2017. We observed clinical and laboratory findings that are not part of TSS criteria, such as pyuria in streptococcal TSS (50% of patients) and pulmonary involvement (85%) and coagulopathy (92%) in nonstreptococcal TSS patients. Recommended treatment with clindamycin and intravenous immunoglobulin was delayed in streptococcal TSS patients without rash (3.37 days vs. 0.87 days in patients with rash), leading to prolonged hospitalization and complications. Incorporation of additional TSS signs and symptoms would be helpful in TSS diagnosis and management.

Paediatrics: how to manage septic shock

Background

Septic shock is a common critical illness associated with high morbidity and mortality in children. This article provides an updated narrative review on the management of septic shock in paediatric practice.

Methods

A PubMed search was performed using the following Medical Subject Headings: "sepsis", "septic shock" and "systemic inflammatory response syndrome". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies and reviews. The search was limited to the English literature and specific to children.

Results

Septic shock is associated with high mortality and morbidity. The outcome can be improved if the diagnosis is made promptly and treatment initiated without delay. Early treatment with antimicrobial therapy, fluid therapy and vasoactive medications, and rapid recognition of the source of sepsis and control are the key recommendations from paediatric sepsis management guidelines.

Conclusion

Most of the current paediatric sepsis guideline recommendations are based on the adult population; therefore, the research gaps in paediatric sepsis management should be addressed.

Clinical Characteristics of Paediatric Hyperinflammatory Syndrome in the Era of Corona Virus Disease 2019 (COVID-19)

The pandemic of COVID-19 initially appeared to cause only a mild illness in children. However, it is now apparent that a small percentage of children can develop a hyperinflammatory syndrome labeled as Pediatric inflammatory multisystem syndrome—temporally associated with SARS-CoV-2 (PIMS-TS) with a phenotype resembling Kawasaki disease (KD) ('Kawa-COVID-19′). Features of this newly recognized condition may include fever, hypotension, severe abdominal pain and cardiac dysfunction, evidence of inflammation, and single or multi organ dysfunction in the absence of other known infections. Children emerge to have mild symptoms compared to adults, perhaps due to reduced expression of the angiotensin converting enzyme (ACE)-2 receptor (the target of SARS-CoV-2) gene, trained innate immunity, and a young and fit immune system. Some of these children may share features of Kawasaki disease, toxic shock syndrome or cytokine storm syndrome. They can deteriorate rapidly and may need intensive care support as well. The PCR test is more often negative although most of the children have antibodies to SARS-CoV-2. Although the pathogenesis is not clearly known, immune-mediated injury has been implicated.

Toxic Shock Syndrome in Patients Younger than 21 Years of Age, United States, 2006-2018

We examined the incidence of toxic shock syndrome in the United States during 2006-2018 among persons <21 years old with commercial or Medicaid-insurance using administrative data. There were 1008 commercially-insured and 481 Medicaid-insured toxic shock syndrome cases. The annual rate was 1 per 100,000 and stable over time. Rates were even lower in children <5 years old and stable over time.

A case report of streptococcal toxic shock syndrome caused by Streptococcus mitis in a healthy adult

BACKGROUND

Streptococcal toxic shock syndrome (STSS) is an acute, multisystem and toxin-mediated disease that usually causes shock and multiple organ failure in the early stages of its clinical course. It is associated with a substantial increase in mortality rate. The disease has been associated with invasive group A Streptococcus and is rarely caused by Streptococcus mitis (S. mitis). In healthy adults, S. mitis is closely related to endocarditis but rarely related to STSS.

CASE PRESENTATION

We report a case of STSS caused by S. mitis in a healthy 45-year-old woman. She presented with fever 14 h after surgery and with hypotension 24 h later, and she subsequently suffered from septic shock, low albumin, dysfunction of coagulation, acute kidney dysfunction, respiratory alkalosis and metabolic acidosis, acute respiratory distress syndrome and cellulitis of the incision. The diagnosis was obtained through clinical manifestation and blood culture examination. The patient was treated with aggressive fluid resuscitation, adequate antibiotics for a total of 4 weeks, respiratory support, and surgical debridement and drainage of the incision. She was discharged after her vital signs returned to normal and the incision healed on day 40 after surgery.

CONCLUSIONS

The diagnosis of STSS is often delayed or missed, which leads to a high mortality rate. It is possible to cure patients if the disease can be identified early and treated with aggressive fluid resuscitation, adequate antibiotics and control of the source of infection. Clinicians should consider the disease in the differential diagnosis of septic shock to prevent death.

Clinical Efficacy of Intravenous Immunoglobulins in Management of Toxic Shock Syndrome: An Updated Literature Review

Toxic shock syndrome (TSS) is an uncommon complication of infection caused by streptococci and staphylococci. It is associated with a high mortality rate. When evaluating patients with shock symptoms from skin or soft tissue sources, a high index of suspicion for TSS must be maintained. Prompt diagnosis and integrative management with surgical intervention, antibiotics, hemodynamic stabilization, and adjuvants like intravenous immunoglobulins improve survival.

Multisystem Inflammatory Syndrome in Children (MIS-C), a Post-viral Myocarditis and Systemic Vasculitis-A Critical Review of Its Pathogenesis and Treatment

MIS-C is a newly defined post-viral myocarditis and inflammatory vasculopathy of children following COVID-19 infection. This review summarizes the literature on diagnosis, parameters of disease severity, and current treatment regimens. The clinical perspective was analyzed in light of potential immunopathogenesis and compared to other post-infectious and inflammatory illnesses of children affecting the heart. In this paradigm, the evidence supports the importance of endothelial injury and activation of the IL-1 pathway as a common determinant among MIS-C, Kawasaki disease, and Acute Rheumatic fever.

[Toxic shock syndrome due to Staphylococcus aureus in a small child, a (clinical or laboratory chemical) visual diagnosis?]

It is reported about the case of a 3-year-old girl who was admitted to hospital with high fever, vomiting, skin rash, dehydration, suspected staphyloderma and for exclusion of a severe acute respiratory syndrome coronavirus type 2-infection (SARS-CoV‑2 infection). The suspicion of a toxic shock syndrome, among other inflammatory diseases as differential diagnoses, was based on profound erythroderma and arterial hypotension. The diagnostic pathway, treatment and clinical course of this rare disease are described.

Staphylococcal toxic shock syndrome in a lactating mother with breast abscess: A case report

Introduction

The highest risk for Staphylococcal Toxic Shock Syndrome are female patients with pre-existing Staphylococcal vaginal colonization who frequently use contraceptive sponges, diaphragms or tampons. In addition patients with burns, soft tissue injures, retained nasal packing, post-abortion, post-surgical, post intrauterine device placement and abscess formation are also at high risk.

Case presentation

A 19 years old female complaint of high fever with altered level of consciousness. She also had history of nausea, vomiting, diarrhea and pain on her left breast for 5 days. She developed desquamation on her palms and soles on the day three of her admission to ICU. Ultrasonography of her left breast showed 2*2*1 cm abscess collection and the culture report from breast abscess showed Staphylococcus aureus, sensitive to clindamycin, vancomycin and resistant to methicillin. She showed clinical improvement after commencing vancomycin and clindamycin as per culture sensitivity report of breast abscess.

Discussion

Toxic shock syndrome secondary to breast abscess in adult is infrequently reported. The diagnosis of Toxic shock syndrome is made by the Centers for Disease Control and Prevention (CDC) definition. Antibiotics for treatment of this condition should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) in combination with either clindamycin or linezolid.

Conclusion

Treatment for breast abscess warrants incision and drainage as important as antibiotics with anti-toxin. Focused history, physical examination, and laboratory investigations are crucial for the diagnosis and management of this condition.

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The average annual incidence of TSS among adults is low and MRSA isolation among those cases is even more rare.

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TSS secondary to breast abscess in adult is infrequently reported.

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Treatment for breast abscess warrants I &D as important as antibiotics with anti-toxin.

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TSS is a potentially deadly condition and it requires prompt recognition and management.

Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of Clinical Presentation, Hypothetical Pathogenesis, and Proposed Management

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in the multisystem inflammatory syndrome in children (MIS-C). The clinical presentation of MIS-C includes fever, severe illness, and the involvement of two or more organ systems, in combination with laboratory evidence of inflammation and laboratory or epidemiologic evidence of SARS-CoV-2 infection. Some features of MIS-C resemble Kawasaki Disease, toxic shock syndrome, and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. The relationship of MIS-C to SARS-CoV-2 infection suggests that the pathogenesis involves post-infectious immune dysregulation. Patients with MIS-C should ideally be managed in a pediatric intensive care environment since rapid clinical deterioration may occur. Specific immunomodulatory therapy depends on the clinical presentation. The relationship between the immune response to SARS-CoV-2 vaccines in development and MIS-C requires further study.

Toxic Shock Syndrome: Still a Timely Diagnosis

BACKGROUND

Toxic shock syndrome (TSS) is an acute, severe, toxin-mediated disease, characterized by fever, hypotension, and multiorgan system involvement. Toxic shock syndrome has made headlines because of its high associated morbidity and mortality rate in previously healthy young females. Incidence peaked in the early 1980s owing to increased usage of ultra-absorbent tampons. After improved patient education and tampon labeling, the incidence of menstrual TSS has declined.

CASE

A previously healthy 14-year-old girl presented to an urgent care center with a 2-day history of fever, erythematous maculopapular rash, vomiting, diarrhea, and malaise. She was found to be tachycardic and hypotensive. Investigations revealed thrombocytopenia, an elevated white count and lactate, and acute kidney injury, consistent with septic shock. Recent tampon usage with menstruation was reported, and a pelvic examination revealed purulent vaginal discharge. The patient was transferred to a pediatric intensive care unit for antibiotic and vasopressor therapy. Vaginal swabs later tested positive for Staphylococcus aureus and TSS toxin-1.

CONCLUSIONS

Although the incidence of TSS has decreased in recent years, it is crucial that clinicians rapidly recognize and treat this life-threatening condition. Emergency physicians should always have a high index of suspicion for TSS in young females presenting without another obvious cause of shock. A pelvic examination should always be completed in these cases.

Breast abscess in a competitive high school swimmer: a case of toxic shock syndrome

Toxic shock syndrome (TSS) is a severe, acute, toxin-mediated disease process characterized by fever, diffuse erythroderma, hypotension, multisystem organ dysfunction and desquamation of skin. TSS represents the most severe form of disease caused by exotoxin-producing strains of Streptococcus pyogenes and Staphylococcus aureus. Menstrual and non-menstrual TSS become significant causes of morbidity and mortality. As a result of public awareness and various campaigns, the majority of TSS cases tend to be non-menstrual related. The clinical course is fulminant and can result in abrupt decompensation and death. Management within the emergency department (ED) includes removal of the potential foreign body, fluid resuscitation, appropriate antibiotics, potential vasopressor support and possible surgical intervention. We present the unique case of a 16-year-old female competitive swimmer who presented to the ED twice, demonstrating the fulminant course of TSS. She initially presented with non-specific symptoms with an unremarkable evaluation. She returned within hours of discharge with an abrupt onset of diffuse macular erythroderma, placed on norepinephrine and was diagnosed with TSS secondary to a breast abscess.

Epidemiology and Clinical Relevance of Toxic Shock Syndrome in US Children

INTRODUCTION

It is important for clinicians to recognize the contribution of toxic shock syndrome (TSS) to the overall burden of pediatric septic shock because the clinical features, optimal therapy and prognosis differ from non-TSS septic shock.

METHODS

We analyzed cases of pediatric septic shock reported to the Pediatric Health Information Systems database between 2009 and 2013 to define the clinical and demographic characteristics of pediatric TSS in the United States. Using a validated International Classification of Diseases, 9th revision, coding strategy, we identified patients with infectious shock among inpatients age 1-18 years and classified cases of staphylococcal and streptococcal TSS for comparison with non-TSS cases.

RESULTS

Of 8,226 cases of pediatric septic shock, 909 (11.1%) were classified as TSS and 562 (6.8%) were possible TSS cases. Staphylococcal TSS represented the majority (83%) of TSS cases and occurred more commonly in females and at an older age. Compared with non-TSS septic shock, TSS had significantly lower fatality rates, disease severity and length of hospital stay and was present more often at the time of admission (P < 0.001 for each). Streptococcal TSS was associated with poorer outcomes than staphylococcal TSS. Treatment for TSS differed from non-TSS septic shock in use of more clindamycin, vancomycin and Intravenous Immunoglobulin and less need for vasopressors.

CONCLUSIONS

Results demonstrate a significant contribution of TSS to the burden of pediatric septic shock in the United States. The findings emphasize the importance of inclusion of TSS diagnostic and therapeutic considerations in sepsis treatment protocols for children.

A systematic review exploring the relationship between infection and sudden unexpected death between 2000 and 2016: A forensic perspective

Death due to infectious diseases is a major health concern worldwide. This is of particular concern in developing countries where poor-socio economic status and a lack of healthcare resources contribute to the high burden of disease. In some cases death due to infection can be acute and aggressive, and death may occur without a diagnosis whilst the person is still alive. These deaths may ultimately lead to a medico-legal autopsy being performed. There are various mechanisms by which sudden death due to infection may occur. In addition, there are many risk factors associated with sudden death due to infection, which differ between infants and older individuals. However, it is unclear which pathogens and risk factors are most frequently associated with sudden death due to infection. Therefore a systematic review of articles and case reports published between 1 January 2000 and 30 June 2016 was undertaken in order to (1) explore the relationship between pathogens and their causative role and (2) identify the relationship between predisposing and/or risk factors associated with sudden death due to infection. Major databases were searched and after critical appraisal 143 articles were identified. It was found that respiratory infections and deaths involving bacterial pathogens were most commonly associated with these deaths. In addition the most common risk factors in infants were exposure to tobacco smoke and co-sleeping. In adults the most common risk factors were co-morbid conditions and illnesses. This information aids in a better understanding of these deaths and highlights the need for more research in this field, particularly in developing countries.

Differences Between Pediatric and Adult T Cell Responses to In Vitro Staphylococcal Enterotoxin B Stimulation

Toxic shock syndrome (TSS) is capable of inducing life-threatening fever, rash, and systemic organ failure, though the specific mechanisms behind these symptoms remain poorly understood. Staphylococcal enterotoxin B (SEB) and other superantigens have shown to be important factors in TSS, capable of promoting cross-linking between T cell receptors and major histocompatibility complexes which results in overwhelming T cell activation, proliferation, and cytokine production. The resulting proinflammatory cytokine cascade, often referred to as the “cytokine storm,” seems to be critical to the development of disease. Interestingly, clinical studies have shown that children exhibit less severe TSS-associated morbidity than adults, though the mechanism behind this phenomenon has not been addressed. Indeed, despite the fact that most novel antigen exposure occurs early in life, be it from environmentally acquired pathogens or routine vaccination, normal pediatric T cell immune functions remain critically underexplored. This is largely due to difficulty in obtaining enough samples to explore more than a narrow sliver of the cell-mediated immune compartment. To address this limitation, we optimized a T effector (T_eff)/circulating T follicular helper (cT_FH) cell mass cytometry panel which allowed us to analyze a wide array of T cell populations and effector functions following in vitro SEB stimulation. We show that T cell activation—as measured by CD69 expression—following SEB stimulation is lower in pediatric participants, increasing throughout childhood, and reaching adult levels by around 15 years old. Further, while individual CD4⁺ effector memory T cell (T_EM) effector molecules show limited age-associated differences following SEB stimulation, multifunctional CD4⁺ T_EM are shown to positively correlate with increasing age through adolescence. Individual CD8⁺ T_EM effectors and multifunctional phenotypes also show very strong age-associated increases following SEB stimulation. SEB stimulation has little impact on cT_FH activation or functional cellular markers, regardless of age. These results, coupled with the fact that a robust proinflammatory cytokine response seems critical to developing severe TSS, suggest a possible connection between the significantly reduced T cell activation and multifunctional populations following in vitro SEB stimulation in our pediatric participants and clinical observations relating to reduced TSS mortality in children.

The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature

BACKGROUND

Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately.

OBJECTIVE

This review provides an emergency medicine evidence-based summary of the current evaluation and treatment of TSS.

DISCUSSION

The most common etiologic agents are Staphylococcus aureus and Streptococcus pyogenes. Sources of TSS include postsurgical wounds, postpartum, postabortion, burns, soft tissue injuries, pharyngitis, and focal infections. Symptoms are due to toxin production and infection focus. Early symptoms include fever, chills, malaise, rash, vomiting, diarrhea, and hypotension. Diffuse erythema and desquamation may occur later in the disease course. Laboratory assessment may demonstrate anemia, thrombocytopenia, elevated liver enzymes, and abnormal coagulation studies. Diagnostic criteria are available to facilitate the diagnosis, but they should not be relied on for definitive diagnosis. Rather, specific situations should trigger consideration of this disease process. Treatment involves intravenous fluids, source control, and antibiotics. Antibiotics should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid.

CONCLUSION

TSS is a potentially deadly disease requiring prompt recognition and treatment. Focused history, physical examination, and laboratory testing are important for the diagnosis and management of this disease. Understanding the evaluation and treatment of TSS can assist providers with effectively managing these patients.

Similarities and Differences Between Staphylococcal and Streptococcal Toxic Shock Syndromes in Children: Results From a 30-Case Cohort

Introduction: Toxic shock syndromes (TSS) are severe shocks due to staphylococcal or streptococcal infection that require specific treatments. The early recognition of these shocks is crucial to improve their outcomes. Objectives: The primary objective of this study was to compare characteristics and outcomes of staphylococcal and streptococcal TSS in children, in order to identify putative early clinical diagnostic criteria. Secondary objectives were to determine the toxin gene profiles of associated isolated strains and the relevance of measuring Vβ T-cell signatures to confirm the diagnosis. Study design: We performed a multicenter retrospective evaluation of clinical data, biological results, and treatment outcomes of children with a confirmed or probable case of staphylococcal or streptococcal TSS. Children were consecutively included if they were admitted to the pediatric intensive care units of Lyon (France), between January 2005 and July 2011. Results: Among the 30 analyzed children, 15 presented staphylococcal TSS and 15 streptococcal TSS. The most frequent origin of staphylococcal and streptococcal TSS was the lower respiratory tract (53%) and the genital tract (47%) respectively. Non-menstrual TSS syndrome cases presented more frequently with neurological alterations, and digestive signs were predominant in menstrual forms. Compared to Staphylococcal TSS, Streptococcal TSS presented with higher organ dysfunction scores (median Pediatric Index of Mortality 2 score 20.9 (4.1-100) vs. 1.7 (1.3-2.3), p = 0.001), required respiratory support more frequently (80 vs. 33%, p = 0.02), were intubated for a longer time (3 days (0.75-5) vs. 1 day (0-1.5), p = 0.006) and had a non-significant trend of higher, case-fatality rate (20 vs. 7%, p = 0.60). The lack of antitoxin therapy was associated with higher case-fatality rate (50 vs. 4%, p = 0.04). The Vβ repertoire measurements exhibited toxin dependent-alterations in accordance with the toxin gene profiles of isolated strains in both types of toxic shock syndromes. Regarding toxin gene profiles of isolated strains, 10/15 Staphylococcus aureus belonged to clonal complex (CC) 30 and 6/12 Streptococcus pyogenes were emm1 type suggesting clonal etiologies for both staphylococcal and streptococcal TSS. Conclusion: Despite the involvement of functionally similar toxins, staphylococcal and streptococcal TSS differed by their clinical signs, origin of infection and prognosis. The detection of Vβ profiles was useful to confirm the diagnosis of staphylococcal and streptococcal TSS and for the identification of involved toxins.

Neutropenia and T-Wave Inversion as Toxin-Mediated Complications of a Streptococcal Infection

Introduction

Streptococcal infection can be responsible for multiple complications, such as toxic, septic or allergic disorders. Toxin-mediated complications (TMC) can appear during the acute phase of disease and can involve any organ, causing carditis, arthritis, nephritis, hepatitis etc.

Case presentation

The case of a young woman without a history of recurrent streptococcal tonsillitis, admitted to “Matei Balş” National Institute for Infectious Diseases, Bucharest, Romania, presenting with fever, sore throat and exudative tonsillitis, is detailed. The initial test for Streptococcus pyogenes was negative. The patient had leukopenia with severe neutropenia, high values of inflammatory biomarkers and electrocardiographic (ECG) changes with inverted T waves in leads V1-4 and flattened T waves in V5-6. There were no other cardiac signs or symptoms. The patient received cefuroxime for two days. On admission, the patient was prescribed Penicillin G and dexamethasone which resulted in a rapid recovery. The leucocytes count returned to normal as did the ECG abnormalities. At the time of discharge, the antistreptolysin O titre was high.

Conclusions

The case highlights the toxin-mediated complications (TMC) of streptococcal infection which occur from the outset of the disease.

Epidemiology and hospital readmission associated with complications of Staphylococcus aureus bacteremia in pediatrics over a 25-year period

We sought to comprehensively assess the prevalence and outcomes of complications associated with Staphylococcus aureus bacteremia (SAB) in children. Secondarily, prevalence of methicillin resistance and outcomes of complications from methicillin-resistant S. aureus (MRSA) vs. methicillin-susceptible S. aureus SAB were assessed. This is a single-center cross-sectional study of 376 patients ⩽18 years old with SAB in 1990-2014. Overall, 197 (52%) patients experienced complications, the most common being osteomyelitis (33%), skin and soft tissue infection (31%), and pneumonia (25%). Patients with complications were older (median 3 vs. 0·7 years, P = 0·05) and more had community-associated SAB (66% vs. 34%, P = 0·001). Fewer patients with complications had a SAB-related emergency department or hospital readmission (10% vs. 19%, P = 0·014). Prevalence of methicillin resistance increased from 1990-1999 to 2000-2009, but decreased in 2010-2014. Complicated MRSA bacteremia resulted in more intensive care unit admissions (66% vs. 47%, P = 0·03) and led to increased likelihood of having ⩾2 foci (58% vs. 26%, P < 0·001). From multivariate analysis, community-associated SAB increased risk and concurrent infections decreased risk of complications (odds ratio (OR) 1·82 (1·1-3·02), P = 0·021) and (OR 0·58 (0·34-0·97), P = 0·038), respectively. In conclusion, children with SAB should be carefully evaluated for complications. Methicillin resistance remains associated with poor outcomes but have decreased in overall prevalence.

The Management of Staphylococcal Toxic Shock Syndrome. A Case Report

Staphylococcal toxic shock syndrome (TSS) is most frequently produced by TSS toxin-1 (TSST-1) and Staphylococcal enterotoxin B (SEB), and only rarely by enterotoxins A, C, D, E, and H. Various clinical pictures can occur depending on severity, patient age and immune status of the host. Severe forms, complicated by sepsis, are associated with a death rate of 50-60%. The case of a Caucasian female infant, aged seven weeks, hospitalized with a diffuse skin rash, characterized as allergodermia, who initially developed TSS with axillary intertrigo, is reported. TSS was confirmed according to 2011 CDC criteria, and blood cultures positive for Methicillin-sensitive Staphylococcus aureus (MSSA). Severe development occurred initial, including acidosis, consumption coagulopathy, multiple organ failures (MOF), including impaired liver and kidney function. Central nervous system damage was manifest by seizures. Clinical management included medical supervision by a multidisciplinary team of infectious diseases specialist and intensive care specialist, as well as the initiation of a complex treatment plan to correct hydro electrolytic imbalances and acidosis. This treatment included antibiotic and antifungal therapy, diuretic therapy, immunoglobulins, and local treatment similar to a patient with burns to prevent superinfection of skin and mucous membranes lesions. There was a favourable response to the treatment with resolution of the illness.

Infectious Diseases and the Kidney in Children

The kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. In most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. Although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. In this chapter, a microbiological classification of the organisms affecting the kidney is adopted. Although they are important causes of renal dysfunction in infectious diseases, urinary tract infections and hemolytic uremic syndrome (HUS) are not discussed in detail because they are considered separately in chapters XX and XX, respectively.

Toxic shock syndrome surveillance in UK children

BACKGROUND

Toxic shock syndrome (TSS) is an acute toxin-mediated illness caused by toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes. There is no recent data regarding incidence, management and mortality of TSS in UK children.

METHODS

Consultants from paediatric and burns units in the UK and Ireland, reported cases of TSS seen between November 2008 and December 2009, via the British Paediatric Surveillance Unit. Respondents were sent questionnaires requesting detailed information about TSS cases. Established criteria were used to divide cases into staphylococcal or streptococcal TSS.

RESULTS

Forty-nine cases were identified overall; 29 cases of streptococcal TSS (18 confirmed and 11 probable) and 20 cases of staphylococcal TSS (15 confirmed and 5 probable). The incidence of TSS children in the UK & the Republic of Ireland was calculated to be 0.38 per 100 000 children. Children with staphylococcal TSS were older than those with streptococcal TSS (9.5 vs 3.8 years; p<0.003). Paediatric intensive care facilities were used for 78% of cases (invasive ventilatory support 69%; inotropic support 67%; haemofiltration 12%). Agents with antitoxin effects were underused; clindamycin 67%, intravenous immunoglobulin (IVIG) 20%, fresh frozen plasma 40%. There were eight deaths, all in the streptococcal group (28% of streptococcal cases)-none were given IVIG.

CONCLUSIONS

Streptococcal TSS was as frequent as staphylococcal TSS, contrasting with previous literature. Children with streptococcal TSS had a higher mortality than those with staphylococcal TSS (28% vs 0%; p<0.05). Recommended immunomodulatory agents (IVIG and clindamycin) were underused. This study highlights the need for a guideline to improve management of TSS in children.

Severe group A streptococcal infections in a paediatric intensive care unit

AIM

To describe the clinical presentation, management and outcomes for children with invasive group A streptococcal (GAS) infection in a paediatric intensive care unit (PICU).

METHODS

We reviewed the clinical and laboratory records of patients admitted to a PICU in Melbourne with invasive GAS infection from April 2010 to April 2013. Outcomes recorded included survival, organ failure, need for extracorporeal support, renal replacement therapy and prolonged neuromuscular weakness.

RESULTS

Twelve cases of invasive GAS infection were identified. The most common clinical presentations were pneumonia (n=5), bacteraemia with no septic focus (n=4) and septic arthritis (n=3). Necrotising fasciitis occurred in one patient and another patient presented with ischaemic lower limbs requiring amputation. Of the eight isolates with available emm typing results, the most common emm type was emm1 (n=4) followed by emm4, 12 and 22. Nine patients had multi-organ failure. Ten patients required mechanical ventilation for a median duration of 8 days. Nine patients required inotropic and/or vasopressor support and four patients extracorporeal membrane oxygenation support. Eleven patients survived. A prolonged period of neuromuscular weakness following the initial severe illness was common (n=5), but most children returned to normal or near normal neurological function.

CONCLUSIONS

Invasive GAS disease in children may cause severe multi-organ failure with resultant prolonged intensive care stay and significant morbidity. However, a high rate of survival and return to normal functioning may be achieved with multi-system intensive care support and multi-disciplinary rehabilitation.