Toxic Shock Syndrome

Caring for the child in shock is challenging! Vascular access has to be attained. Fluids have to be given quickly and Vasopressors may need to be started early! Certainly, the airway must be evaluated and, occasionally, secured. All of this occurs while we juggle the potential causes (ex, Sepsis, Hypovolemia, Obstructive processes, Cardiogenic, “K“ortisol). For children, the potential for an infectious etiology is always high, but this may warrant more consideration than “just give them all of the antibiotics we have!” Do not overlook the potential for bacterial TOXINS causing more problems for the patient! Let’s take a moment to review Toxic Shock Syndrome:

Toxic Shock Syndrome: Basics

  • Toxic Shock Syndrome (TSS) is: [Javouhey, 2018]
    • Severe, acute illness
      • May begin with non-specific symptoms (GI particularly). [Javouhey, 2018; Rodriguez-Nunez, 2011]
      • Rapid clinical deterioration follows.
    • Characterized by:
      • High Fever
      • Hypotension
      • Rash (ex, erythroderma, scartletiniform, intertrigo)
      • Multi-Organ System Dysfunction (ex, Altered Mental Status, Renal dysfunction)
      • Desquamation (during convalescence)
  • TSS is difficult to diagnose as the characteristics may be transient, absent, or delayed in presentation. [Javouhey, 2018]
    • Often not initially recognized. [Javouhey, 2018; Deniskin, 2018; Rodriguez-Nunez, 2011]
    • Clindamycin (part of recommended therapy) was not given as part of initial therapy in a substantial portion of cases of TSS. [Gaensbauer, 2018; Deniskin, 2018; Rodriguez-Nunez, 2011]
  • TSS is caused by SUPERantigen ExoTOXINS. [Javouhey, 2018]
    • Superantigens directly stimulate T cells
      • They do not need to be processed by antigen-presenting cells.
      • Superantigens lead to massive polyclonal cell proliferation!
    • Superantigens can be produced by both Staph and Strep.
    • Superantigens are very potent.
  • TSS should be considered in critically ill children with:
    • Erythroderma
    • Conjunctival Hyperemia
    • Strawberry tongue
    • Known nidus of infection (ex, tampon, nasal / wound packing)
  • TSS may look very similar many other conditions like:
  • TSS can be caused by Staphylococcus or Streptococcus.
    • Staphylococcus is the most common etiology of TSS. [Gaensbauer, 2018; Javouhey, 2018]
      • Staph TSS more frequently occurs in older, female patients associated with menstruation.
      • Staph TSS does, however, also occur in males and other aged children.
    • Streptococcal TSS is less common overall, but: [Gaensbauer, 2018; Javouhey, 2018]
      • Strep TSS is more common in younger children (~47% of patients < 2 years of age)
      • Strep TSS is more clinically severe.
      • TSS associated with para-pneumonic empyema is suggestive of strep etiology.
      • Other risk factors for Strep TSS include: [Rodriguez-Nunez, 2011]
        • Previous surgery
        • Skin Wounds
        • Trauma
        • Recent Viral Infection (ex, Varicella Zoster, Influenza) [Rodriguez-Nunez, 2011]
        • NSAID use
        • Premature birth
        • Congenital heart disease
        • Immune Suppression

Toxic Shock Syndrome: Management

  • Rapid recognition and initiation of treatment of Septic Shock is critical to helping to support good outcomes. [Gaensbauer, 2018]
    • Recognition of shock is challenging in children – Assess Cap Refill!
    • Rapid diagnostic testing can be helpful (although an elevated Lactate can be from other conditions).
    • Aggressively volume resuscitate!
    • “Timely” initiation of broad spectrum antibiotics (many protocols call from them to be given within the 1st 60 min).
  • Toxic Shock Syndrome was estimated in ~11% of all septic shock cases. [Gaensbauer, 2018]
  • In addition to the above, optimal treatment of Toxic Shock Syndrome should include: [Gaensbauer, 2018; Javouhey, 2018]
    • Elimination of any nidus of toxin-producing staph or strep
      • Removal of foreign bodies (ex, tampons, nasal packing)
      • Surgical drainage of abscess / deep space infection
    • Reduction of toxin production / exposure
      • Antibiotics like Clindamycin, Rifampin, or Linezolid interfere with exotoxin production. [Javouhey, 2018]
      • Some data support use of IVIG to neutralize the Superantigens. [Javouhey, 2018]
  • It is important to ensure that Clindamycin (or another exotoxin production inhibitor) is added to your broad-spectrum antibiotics selected based on your regional antibiogram. [Rodriguez-Nunez, 2011]

Moral of the Morsel

  • Some bugs are really vicious! The weapons that Staph and Strep possess are quite impressive and aggressive!
  • Keep Toxic Shock Syndrome on your list! You may be correct in diagnosing that cause of the shock is infection, but don’t overlook the possible circulating bacterial exotoxins!
  • Fight the Toxins! Add Clindamycin to your protocoled antibiotic selections.

References

Gaensbauer JT1,2,3, Birkholz M3, Smit MA4, Garcia R5, Todd JK2,3. Epidemiology and Clinical Relevance of Toxic Shock Syndrome in US Children. Pediatr Infect Dis J. 2018 Dec;37(12):1223-1226. PMID: 29601458. [PubMed] [Read by QxMD]
Javouhey E1,2, Bolze PA3, Jamen C1, Lina G4,5,6, Badiou C6, Poyart C7,8,9,10, Portefaix A1,11, Tristan A2,4,5,6, Laurent F2,4,5,6, Bes M4,6, Vandenesch F2,4,5,6, Gilletand Y1,4,6, Dauwalder O4,5,6. Similarities and Differences Between Staphylococcal and Streptococcal Toxic Shock Syndromes in Children: Results From a 30-Case Cohort. Front Pediatr. 2018 Nov 28;6:360. PMID: 30547021. [PubMed] [Read by QxMD]
Deniskin R1, Shah B2, Muñoz FM1,3, Flores AR2. Clinical Manifestations and Bacterial Genomic Analysis of Group A Streptococcus Strains That Cause Pediatric Toxic Shock Syndrome. J Pediatric Infect Dis Soc. 2018 Jul 31. PMID: 30085250. [PubMed] [Read by QxMD]
Daskalaki MA1, Boeckx WD, DeMey A, Franck D. Toxic shock syndrome due to group A beta-hemolytic streptococcus presenting with purpura fulminans and limb ischemia in a pediatric patient treated with early microsurgical arteriolysis. J Pediatr Surg. 2013 Jan;48(1):e1-3. PMID: 23331831. [PubMed] [Read by QxMD]
Rodríguez-Nuñez A1, Dosil-Gallardo S, Jordan I; ad hoc Streptococcal Toxic Shock Syndrome collaborative group of Spanish Society of Pediatric Intensive Care. Clinical characteristics of children with group A streptococcal toxic shock syndrome admitted to pediatric intensive care units. Eur J Pediatr. 2011 May;170(5):639-44. PMID: 20981441. [PubMed] [Read by QxMD]
Young AE1, Thornton KL. Toxic shock syndrome in burns: diagnosis and management. Arch Dis Child Educ Pract Ed. 2007 Aug;92(4):ep97-100. PMID: 17644672. [PubMed] [Read by QxMD]
Laupland KB1, Davies HD, Low DE, Schwartz B, Green K, McGeer A. Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Ontario Group A Streptococcal Study Group. Pediatrics. 2000 May;105(5):E60. PMID: 10799624. [PubMed] [Read by QxMD]
Pichichero ME1. Group A beta-hemolytic streptococcal infections. Pediatr Rev. 1998 Sep;19(9):291-302. PMID: 9745311. [PubMed] [Read by QxMD]
Nields H1, Kessler SC, Boisot S, Evans R. Streptococcal toxic shock syndrome presenting as suspected child abuse. Am J Forensic Med Pathol. 1998 Mar;19(1):93-7. PMID: 9539401. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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