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

## TL;DR

This study reviews 18 years of pediatric toxic shock syndrome cases, comparing staphylococcal and streptococcal causes and highlighting disease severity and treatment outcomes.

## Contribution

The study provides a detailed analysis of TSS in a pediatric ICU, noting increased streptococcal TSS cases post-COVID-19.

## Key findings

- Streptococcal TSS cases increased since the start of the COVID-19 pandemic.
- Staphylococcal TSS was associated with more muscular involvement compared to streptococcal TSS.
- All TSS patients required multiple antibiotics and intensive care, with higher albumin infusion rates in streptococcal cases.

## 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.