Toxic shock syndrome in scalded children

doi:10.1016/0305-4179(90)90045-X

Burns

Volume 16, Issue 3, June 1990, Pages 221-224

https://doi.org/10.1016/0305-4179(90)90045-X Get rights and content

Abstract

Five patients showing clinical signs resembling the ‘toxic shock syndrome’ presented over a 4-month period at the Wessex Regional Burns Centre. Toxin-producing isolates of Staphylococcus aureus were made from wound swabs in four of the five patients. Four different phage types producing four different toxins were observed. Seven other patients yielded staphylococci from wound swabs but did not develop the toxic shock syndrome. In three of these latter patients the staphylococcus isolated was toxin producing. Since the syndrome carries a significant mortality risk it is desirable that it is recognized and treated without delay. To this end a simplified set of criteria for the identification of probable toxic shock syndrome cases is proposed. The observations suggest that toxic shock syndrome is more common than previously supposed. The syndrome may show a broad spectrum in its clinical presentation, and involve a wide range of staphylococcal phage types with possible involvement of several different enterotoxins.

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Treatment of Burns

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Cited by (46)

Toxic shock syndrome in paediatric thermal injuries: A case series and systematic literature review
2018, Burns
Citation Excerpt :
When compared to adults, children are less likely to develop all classic symptoms required for a TSS-diagnosis. For these reasons Cole and Shakespeare [6] published an abbreviated list of diagnostic criteria specifically for children, consisting of pyrexia, rash, diarrhoea and/or vomiting, irritability and lymphopenia. These specific paediatric diagnostic criteria are helpful to clinicians as they may enable specific and early TSS-diagnosis in children with thermal injuries, potentially resulting in more favourable outcomes.
Toxic shock syndrome (TSS) is a rare, but potentially life-threatening complication of thermal injuries in children. The study objective was to systematically review the literature on paediatric TSS after burns or scalds, and describe our experience with this condition in Switzerland.
All tertiary paediatric healthcare centres managing burns and scalds in Switzerland were inquired. A systematic literature review was performed using EMBASE (1947–2016), MEDLINE (1946–2016), Web of Science (1900–2016) and Google Scholar in October 2016. Data on patient characteristics, symptoms, laboratory parameters, management and outcome were extracted from paper and electronic patient charts. Descriptive statistics were performed.
The literature review revealed 25 articles describing 59 cases observed in 10 countries (UK, USA, Hungary, Austria, Sweden, Denmark, Israel, Japan, Spain, Switzerland) from 1985 to 2016. The patient age ranged from 8 months to 8 years at the time point of TSS-diagnosis. The injured total body surface area ranged from <1% to 41%. Forty-one patients suffered from scalds, 6 from burns and in 12 cases the type of injury was not specified. The TSS-diagnosis was made 1–7 days after thermal injury. Nineteen children underwent admission to the Intensive Care Unit. Six children died from TSS. In Switzerland, we identified 11 consecutive cases between 07/2001 and 06/2011 (median age 15 months, range 9 months–14 years; 9 male, 2 female; 3 burns, 8 scalds; 7% median total body surface area (TBSA), range 2–30%). Diagnosis of TSS was made on day 5 after injury in median (range 3–34 days). Eight of eleven patients received intensive care. Survivors (10/11) suffered no long-term sequelae besides scars. One 13-month old boy died 3 days after a 7%-TBSA scald.
Toxic shock syndrome is an important complication of paediatric burns in Switzerland and several other countries world-wide. Diagnosis and management remain challenging. Awareness among treating clinicians is crucial for a favourable outcome.
TOXIC SHOCK SYNDROME
2009, Feigin and Cherry's Textbook of Pediatric Infectious Diseases, Sixth Edition
Successful management using combination therapy of endotoxin absorption therapy (PMX) and continuous hemodiafiltration (CVVHDF) of a critically ill burn patient suffering from methicillin-resistant Staphylococcus aureus toxic shock syndrome
2008, Burns
Prevalence of toxin producing strains of Staphylococcus aureus in a pediatric burns unit
2007, Burns
Citation Excerpt :
Hospitalised patients are more at risk of becoming colonized [7]. In a study of burned children, Cole and Shakespeare [8] recovered strains of S. aureus that were capable of producing superantigen toxins such as TSST-1. Toxic shock syndrome is a rare but serious consequence of burn wound infection [9–13].
The aims of the study were to determine the sites in a pediatric burns unit that were contaminated with Staphylococcus aureus. Samples from the environment in bedrooms and the common room were taken monthly for 6 months using blood agar for total counts and Baird-Parker agar for S. aureus. The air was sampled using an air-sampling device and settle plates. Hard and soft surfaces including bed, blanket, sofa, chair, taps, bathtub, soft toys, locker and cupboard in the same rooms were sampled using contact plates. Swabs were taken from staff monthly for 3 months. S. aureus isolates were tested for production of enterotoxins A–D and toxic shock syndrome toxin-1 using a reverse passive latex agglutination test. The results showed that S. aureus was recovered more frequently using settle plates than using the air sampler. All surfaces sampled were contaminated with S. aureus and contamination was greatest in frequently occupied rooms. A variety of toxin producing isolates were found with enterotoxin C isolates, either alone or in combination with TSST-1 (toxic shock syndrome toxin-1) dominant. The staff were transiently colonised with S. aureus strains with a different toxin production pattern. The results show that airborne transmission may be a route for infection by S. aureus and is responsible for contaminating the environment.
Early burn related gram positive systemic infection in children admitted to a pediatric surgical ward
2006, Burns
Gram positive infections, including toxic shock syndrome (TSS), may be an early complication following burns, especially in children.
To identify risk factors associated with early burn related gram positive systemic infection (EBGI) in children admitted to a Pediatric Surgical Ward.
A retrospective analysis of the records of all EBGI patients treated from January 1995 to December 2004. EBGI patients were defined as having systemic signs of infection appearing in the first 48 h following the burn and associated with: (1) clinical signs of toxin mediated illness and/or (2) positive blood culture of either Staphylococcus aureus or group A beta hemolytic Streptococcus. Demographic and clinical data were also collected from the charts of 150 randomly selected burn patients admitted during the study period.
We identified 13 cases of EBGI (2.5%) among 518 children admitted for thermal burns (mean age: 2.4 years). Three had bacteremia without rash. The 10 other patients were diagnosed as having a toxin mediated disease. S. aureus grew from the burn wound in six patients. All EBGI patients recovered following antibiotic therapy. Significant differences between the groups included: percentage of burned body surface area (6.9% versus 3.9%), and head and face localization (64% versus 31%) in the EBGI and control groups, respectively.
EBGI is not rare even in pediatric patients with minor–moderate burns. Burns localized to the face or the head may be predisposing factor for such an infection.
On the use of prophylactic antibiotics in prevention of toxic shock syndrome
2005, Burns
No consensus exists among burn surgeons on the role of prophylactic antibiotics in prevention of toxic shock syndrome (TSS). We recently reported a series of 71 children admitted with burns to our burn unit. By Centres for Disease Control (CDC) criteria, six of these were ‘definite’ and four ‘probable’ cases of TSS. Prior to this report, none of our patients were given prophylactic antibiotics. Thereafter, prophylactic therapy was included in the management of children admitted to the burns unit. The aim of this study was to assess whether prophylaxis with a one off single dose of systemic antibiotics prevented the occurrence of TSS.
Data were collected prospectively between 1 January and 31 December 2001, on all children admitted to the burns unit. Out of 50 children admitted to the burns unit, 39 received prophylactic antibiotics in the referring accident and emergency. Two of these became unwell but none fulfilled the CDC criteria. The remaining 11 patients were given antibiotics on admission out of which one child required direct admission to the intensive care unit with a working diagnosis of TSS. Retrospectively, his features did not conform to the CDC criteria. In conclusion, this study suggests that prophylaxis may prevent TSS in children.

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^☆: Since this paper was prepared the simplified criteria have been used prospectively to identify three further cases of ‘probable’ TSS in scalded children. All three cases showed wound colonization with Staphylococcus aureus, two of which were phage typable. All three isolates were toxin producing, the non-typable isolate producing SEB, the typable isolates (29/52 and 29/52/79) both producing TSST-1.

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Burns

Abstract

References (22)

Early lymphopenia in burned children with and without the toxic shock syndrome

Burns

The toxic shock syndrome in a burn victim

Burns

Skin and soft tissue infections

Lancet

The toxic shock syndrome in burned children

Burns

Mupirocin-resistant Staphylococcus aureus

Lancet

Toxic shock syndrome associated with phage group-I staphylococci

Lancet

Spread of a toxic-shock syndrome associated strain of Staphylococcus aureus and measurement of antibodies to staphylococcal enterotoxin F

J. Infect. Dis.

Mupirocin-resistant Staphylococcus aureus

Lancet

Toxic Strep. syndrome

Arch. Intern. Med.

Treatment of Burns

Follow-up on Toxic Shock Syndrome

MMWR

Cited by (46)

Toxic shock syndrome in paediatric thermal injuries: A case series and systematic literature review