Elsevier

Burns

Volume 44, Issue 1, February 2018, Pages e1-e12
Burns

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

https://doi.org/10.1016/j.burns.2017.07.002Get rights and content

Highlights

  • Toxic shock syndrome is a rare, but life-threatening complication of paediatric burns.

  • Toxic shock syndrome diagnosis is challenging in the acute setting, as it is based on clinical signs and symptoms.

  • Rapid treatment initiation with a low level of suspicion is required for favourable outcomes.

  • Many aspects such as risk factors, outcome predictors, prevention and genetic predisposition remain unclear.

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Introduction

Toxic shock syndrome (TSS) in previously healthy children has first been described by Todd et al. in 1978 [1]. Seven years after the first paediatric TSS-report, TSS was observed in seven children with thermal injuries [2]. Besides these occurrences, TSS has mainly been observed in menstruating women using superabsorbent tampons [3]. Today TSS in burns is typically associated with children aged 1–4 years two days after suffering from a small burn [4]. The toxin-mediated disease represents the most common cause of death in the paediatric population with small thermal injuries [4]. While diagnosis remains challenging, mortality from TSS is completely preventable by early diagnosis and aggressive treatment [4].

The diagnosis of TSS in paediatric burns is made clinically, but is challenging due to non-specific clinical signs and the disease’s ability to mimic other childhood illnesses [4]. A child with sudden deterioration after a minor thermal injury should be worked-up for TSS and a high level of suspicion should be maintained. Diagnostic criteria have been published to facilitate diagnosis [5], [6]. The generic diagnostic criteria proposed by the Centers for Disease Control and Prevention (CDC) have been abbreviated and revised to make them more applicable to the paediatric burn population by Cole et al. in 1990 [5], [6]: fever  39 °C, rash, diarrhoea ± vomiting, irritability and lymphopenia. Three of the 5 abbreviated, age-specific and disease-specific criteria are required for TSS-diagnosis [6]. Toxin testing is rarely useful in the acute setting as the results typically take several days to weeks to return [7]. Once TSS is suspected, treatment has to be initiated quickly due to the rapid progression of the disease. The management typically consists of four main routes: first, resuscitation and stabilization; second, inspection and cleaning of the burn wound; third, anti-staphylococcal and anti-streptococcal antibiotics; fourth, passive immunity against staphylococcal toxic shock syndrome toxin-1 (TSST-1) with fresh frozen plasma (FFP) or intravenous immunoglobulin (IVIG) [4].

Awareness of TSS in paediatric thermal injuries has been perceived as increasing among healthcare professionals. While there are multiple reports from the United Kingdom on TSS in paediatric burns, other countries explicitly report the absence of this condition in their country [8]. This uneven geographical distribution and small number of TSS-cases in paediatric burns makes continuous reporting of case series crucial to increase knowledge and evidence on this condition. An individual case of TSS in a paediatric burn has been reported in Switzerland recently [26]. However, a systematic evaluation of paediatric TSS-cases after thermal injuries in Switzerland and in the medical literature has not been performed to date.

The objective of this study was to describe clinical presentation, management and outcome of children, who suffered from TSS after a thermal injury in Switzerland, and to systematically review the literature and pool the published paediatric cases of TSS after burns.

Section snippets

Systematic literature review

In October 2016 EMBASE (1947–2016), MEDLINE (1946–2016) and the Web of Science (1900–2016) were searched for eligible articles reporting paediatric cases of TSS after thermal injury. In addition, Google Scholar was searched for case series and case reports published in the grey literature. The references from included articles were reviewed as well. The following search terms were used: pediatric, paediatric, child, toddler, neonate, newborn, burn, scald, thermal injury, frostbite, chilblains,

Systematic literature review

The systematic literature review revealed 25 publications reporting 59 paediatric TSS-cases after thermal injury [2], [6], [7], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30]. The reports were published between 1985 and 2016, and they originated from 10 different countries. Thirty-three cases (56%) were reported from the United Kingdom, 10 (17%) from Israel, 5 (8%) from the United States and 3 from Sweden and

Discussion

Although historically TSS has primarily been associated with menstruating women using superabsorbent tampons [3], there has been an increasing awareness of TSS in children with minor burns and scalds among healthcare professionals, which has particularly been fuelled by case reports from the United Kingdom [2], [6], [7], [10], [11], [13], [19], [20], [25], [27]. Toxic shock syndrome is a disease most frequently caused by TSST-1 producing S. aureus [31], but also Group A Streptococcus,

Conclusions

While burns and scalds in childhood are common, TSS remains a rare and life-threatening complication. Toxic shock syndrome diagnosis is challenging as it is based on clinical signs and symptoms, while rapid treatment initiation with a low level of suspicion is indicated for favourable outcomes. Due to the rarity of the disease many questions such as risk factors, prevention or genetic predisposition remain unanswered and warrant future prospective multi-centre studies.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (36)

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