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

Abstract

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.

Keywords: paediatric intensive care unit (picu stay); pediatrics; staphylococcus; streptococcus; toxic shock syndrome.

Figure 1. The frequency of toxic shock syndrome cases during the study period.

Staph-TSS: Staphylococcal toxic shock syndrome; Strep-TSS: Streptococcal toxic shock syndrome.