Toxic shock syndrome occurring in children with abrasive injuries beneath casts.

Staphylococcal toxic shock syndrome has been reported in a number of nonmenstrual settings, including orthopedic patients with postoperative staphylococcal wound infections. We describe two cases of toxic shock syndrome in children with focal cutaneous staphylococcal infections occurring beneath casts placed for limb immobilization. These cases illustrate a new and potentially hidden site of staphylococcal infection leading to toxic shock syndrome.     

Bilateral septic arthritis of the hip with osteitis and psoas abcess in a 17-year-old adolescent

Septic arthritis remains an important and serious disease of the young because of its high potential to cause permanent sequelae. The hip is the most commonly involved joint in infants and in the young (35%). Most often, patients have a single joint involved. We report here a rare case of septic arthritis reaching both hips, shown by a severe septicemic shock and complicated unusually by a psoas abcess and osteitis in an immunocompetent adolescent.     

Salmonella osteitis and septic arthritis

We reviewed 16 patients with salmonella osteitis or septic arthritis. All patients were immunologically normal and none had a history of typhoid fever. We discuss the importance of obtaining a bacteriological diagnosis and provide guidelines on the duration of antibiotic treatment.     

Extracorporeal membrane oxygenation therapy in neonates with septic shock

Neonatal septic shock has significant morbidity and mortality with current therapeutic measures. At Children's National Medical Center, from June 1984 to October 1986, 10 of 100 patients treated with venoarterial extracorporeal membrane oxygenation (ECMO) had a documented diagnosis of septic shock. All of these infants fulfilled criteria consistent with 80% mortality using conventional intensive medical management. However, the survival rate for the septic neonates in this study was 100%. Compared with other groups of infants treated with ECMO, these septic neonates required significantly more ventilatory support after ECMO and had a higher incidence of chronic lung disease (30% v 12%). The septic neonates were also at higher risk for intracranial hemorrhage than the other infants treated with ECMO (40% v 26%). The necessity for prolonged intubation after ECMO for patients with septic shock suggests that this condition may be associated with additional structural damage not seen with meconium aspiration syndrome or respiratory distress syndrome. Nevertheless, for neonatal patients with septic shock unresponsive to conventional medical management, ECMO must be considered a viable alternative treatment.     

Streptococcal toxic shock-like syndrome. The importance of surgical intervention.

Pyrogenic exotoxins A, B, and C produced by group A beta-hemolytic streptococci (Streptococcus pyogenes) may cause a syndrome characterized by fever, rash, desquamation, hypotension, and multi-organ-system dysfunction. This syndrome, the streptococcal toxic shock-like syndrome (TSLS), has a rapid and fulminant course closely resembling the staphylococcal toxic shock syndrome (TSS) caused by the staphylococcal toxic shock syndrome toxin-1 (TSST-1). The recent recognition of this syndrome is thought to stem from the appearance of more virulent strains of streptococci that have a greater tendency to produce potent exotoxins than prior strains. During the past 6 years, the authors have treated six patients with TSLS; three of these patients have presented recently. The sites of streptococcal infection associated with the development of the syndrome are frequently in soft tissue and skin. Early diagnosis, treatment with penicillin, and radical operative debridement are required.     

Toxic shock syndrome in scalded children

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.     

Pyogenic psoas abscess: difficulty in early diagnosis

AIM: To report on the clinical features, diagnosis, and treatment of psoas abscess (PA) with special attention to the presence of septic shock. PATIENTS AND METHODS: This study included 17 patients (mean age 66.2, range 43-81 years) with PA. Treatment consisted of intravenous administration of antibiotics and abscess drainage, either surgical or percutaneous with ultrasound guidance. RESULTS: The typical patients presented with fever >38 degrees C (16/17, 94%), pain in back, flank, or abdomen (15/17, 88%), hip flexion contracture with pain extension (14/17, 82%), and mass felt in the flank (5/17, 29%). All 8 patients without septic shock (100%) had the clinical triad (fever, pain in back, flank, or abdomen, and hip flexion contracture) as compared with 4 of 9 patients with septic shock (44%) (p = 0.012). The duration of symptoms before hospitalization was significantly shorter in the patients with septic shock (median 2, range 1-5 days) than in those without septic shock (median 18.5, range 11-63 days; (p = 0.0005). The mortality rates were 33% (3 of 9) and 0% (0 of 8) in the patients with and without septic shock, respectively (p = 0.071). CONCLUSIONS: PA patients with septic shock had a tendency to have nonspecific symptoms and an occult clinical course as compared with those without septic shock. A delay in diagnosis and treatment can result in a worse clinical outcome (death or totally disabled state). Increased awareness of this condition should lead to earlier diagnosis and treatment with improved outcomes.     

Toxic shock syndrome in a scald burn victim

A child with 12% total body surface area superficial and partial-thickness burns was admitted to the Oregon Burn Center. Within 48 hours of admission, signs and symptoms of toxic shock syndrome (TSS) were present including high spiking fevers, vomiting, diarrhea, hypotension, conjunctival hyperemia, and a diffuse macular erythroderma. Cultures of skin pustules and burn wounds grew Staphylococcus aureus. This strain has been shown to produce staphylococcal enterotoxin B (SEB). This case appears to be the first reported of toxic shock syndrome in a burn victim caused by staphylococcal enterotoxin B.     

Lyme arthritis presenting as acute septic arthritis in children

There is considerable overlap in the initial clinical and laboratory presentations of acute septic arthritis and Lyme arthritis. The authors present a consecutive case series of 10 children with acute arthritis consistent with septic arthritis who ultimately were diagnosed with Lyme disease. Fifty percent presented with a fever of 38 degrees C or higher. The peripheral white blood cell count and differential were not elevated, but the erythrocyte sedimentation rate and the C-reactive protein were significantly elevated. The joint fluid cell count was elevated, with 91% neutrophils. Seven patients in this series underwent emergent joint irrigation and debridement for presumed septic arthritis. The authors suggest that in regions where Lyme disease is endemic, children who present with presumed septic arthritis should also be evaluated for Lyme disease. The authors also present a protocol for evaluation and management of these diagnostically challenging cases.     

Disorders of the sacro-iliac joint in children

The cases of seventeen children whose ages ranged from two to eighteen years and who were treated for a disorder of a sacro-iliac joint between 1975 and 1983 were reviewed retrospectively. Thirteen children were acutely ill, with a temperature of more than 38 degrees Celsius, and four had chronic symptoms that had persisted for three weeks to one year. Pain in the hip, thigh, and buttock was the most common symptom. Of the thirteen acutely ill patients, eleven had septic arthritis of a sacro-iliac joint, while one who had ankylosing spondylitis and one who had juvenile rheumatoid arthritis had acutely painful arthritis of a sacro-iliac joint. Of the four patients who had chronic symptoms, two had septic arthritis of a sacro-iliac joint; one, ankylosing spondylitis with sacro-iliac involvement; and one, eosinophilic granuloma of the ilium. Thus, thirteen patients had septic arthritis of a sacro-iliac joint and four had some other disorder. For the seventeen children who had acute or chronic symptoms, at admission the white blood-cell count ranged from 3,500 to 26,200 per cubic millimeter (average, 11,100 per cubic millimeter) and the sedimentation rate, as determined by the Westergren technique, ranged from twenty-two to sixty-five millimeters per hour (average, fifty millimeters per hour). Twelve of the plain radiographs of the seventeen patients were negative. The initial bone scans of all seventeen patients were positive in eleven and negative in six. Of these six, five had septic arthritis and one, juvenile rheumatoid arthritis. A computed tomographic scan was performed in four patients and was positive in all of them: three had septic arthritis and one had ankylosing spondylitis. Organisms were cultured successfully from blood, from material aspirated from the sacro-iliac joint, or from stool of all thirteen patients who had sepsis. The thirteen infections responded well to appropriate antibiotics, which were administered intravenously to seven patients and first intravenously and then orally to six.     

急腹症与休克(附140例分析)

目的 探讨外科急腹症合并感染性或出血性休克时的临床处理。方法 回顾性分析１４０便急腹症与休克的临床资料。结果 １４０例病人中感染性休克占５５．７％,原发病多为急性梗阻性化脓性胆管炎（ＡＯＳＣ）;出血性休克占４４．３％,多为外伤性肝脾破裂出血。抗休克治疗后,１３１例经手术治疗,治愈率为６８．７％,非手术治疗９例,均死亡。治疗中发生急性呼吸窘迫综合征（ＡＲＤＳ）３４例,总发生率为２４．３％,计感染休克     

Severe group a streptococcal infection and streptococcal toxic shock syndrome

PURPOSE: To review the literature on group A streptococcal toxic shock syndrome, (STSS). DATA SOURCE: Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also searched using key words intravenous immunoglobulin, (IVIG) and group A streptococcus, (GAS); and group A streptococcus and antibiotic therapy. Other references were included in this review if they addressed the history, microbiology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed were also considered. Articles on the foregoing topics were included regardless of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically searched. PRINCIPAL FINDINGS: Reports of invasive GAS infections have recently increased. Invasive GAS infection is associated with a toxic shock syndrome, (STSS), in 8-14% of cases. The STSS characteristically results in shock and multi-organ failure soon after the onset of symptoms, and is associated with a mortality of 33-81%. Many of these patients will require extensive soft tissue debridement or amputation in the operating room, on an emergency basis. The extent of tissue debridement required is often underestimated before skin incision. CONCLUSIONS: Management of STSS requires volume resuscitation, vasopressor/inotrope infusion, antibiotic therapy and supportive care in an intensive care unit, usually including mechanical ventilation. Intravenous immunoglobulin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic management of patients with septic shock.     

Relative adrenal insufficiency in etomidate-naïve patients with septic shock

A recent study reported that 77% of patients with septic shock had relative adrenal insufficiency. However, all patients were mechanically ventilated and received high-dose inotropes. In addition, at least 24% had prior exposure to etomidate, a drug known to suppress adrenal function. We studied the incidence of relative adrenal insufficiency in etomidate-na?ve patients with septic shock by analysing the adrenal response to high-dose short synacthen test in 113 consecutive patients from three university-affiliated intensive care units in Australia. Patients were allocated to three groups according to severity of illness and inclusion criteria of the trial of low dose hydrocortisone supplementation using information from patient records. Of the 113 patients, 98 had septic shock (Group A). The incidence of relative adrenal insufficiency in this subpopulation was 24.5%. Eighty-one per cent of patients with septic shock were mechanically ventilated (Group B). In this group, the incidence of relative adrenal insufficiency was 27.8%. Only 38 of the 98 patients with septic shock (39%) fulfilled inclusion criteria for the steroid supplementation trial (Group C). In this group, the incidence of relative adrenal insufficiency was only 34.2%. In all groups its presence was associated with a higher mortality. We conclude that the incidence of relative adrenal insufficiency in etomidate-naive septic shock patients was lower than observed in the steroid supplementation trial. Further, in those who fulfilled inclusion criteria for the trial, the incidence of relative adrenal insufficiency was half that reported by the trial. Our observations raise concerns about the generalizability of the findings of the above trial to etomidate-na?ve patients.     

Outcome of patients with sepsis and septic shock after ICU treatment

Objective: Today, sepsis syndrome is the leading cause of death in adult, non-coronary intensive care units (ICUs) and is of great clinical importance. The purpose of this review was to evaluate recent prospective studies concerning the short- and long-term prognosis of patients suffering from systemic inflammatory-response syndrome (SIRS), sepsis, severe sepsis and septic shock. It has been shown in multicentre prospective surveys that 1% and 0.3% of all patients admitted to hospitals suffer, respectively, from bacteraemia alone and bacteraemia with severe sepsis. This rate increases, of course, when only admissions to the ICUs are considered: the above-mentioned rates increase then by a factor of 8 and 30, respectively. Thus, approximately 10% of patients in the ICU suffer from sepsis, 6% from severe sepsis and 2–3% from septic shock. SIRS occurs more frequently and its occurrence ranges from 40% to 70% of all patients admitted to ICUs. Thereby, 40–70% suffering from SIRS progress to a more severe septic-disease state. The overall prognosis is still poor, despite the recent advances in ICU treatment. The mortality rate of SIRS ranges from 6% to 7% and in septic shock amounts to over 50%. In particular, abdominal sepsis exhibits the highest mortality rate with 72%. The long-term prognosis is equally poor; only approximately 30% survived the first year after hospital admission. Conclusion: The prognosis of sepsis and septic shock remains poor, despite the advances in ICU treatment. Although prognostic factors have been identified for some patients, groups have not yet been able to identify the immediate or long-term prognosis for the majority of these septic patients. Received: 13 January 1998     

Septic arthritis in the elderly

Twenty-one patients older than 60 years of age with septic arthritis were reviewed over a ten-year period. The knee was the joint most commonly involved. Concurrent medical illnesses were noted in the majority of patients, with diabetes mellitus present in 24%. Seventy-one percent of patients had roentgenographic evidence of preexisting joint disease in the affected joint. Most patients were afebrile and had normal white blood cell counts at the time of admission. The erythrocyte sedimentation rate was elevated in all patients tested, with an average value of 79. Despite surgical treatment in the majority of patients, the complication rate was high, with 38% developing osteomyelitis; 14%, secondary osteoarthritis; and 19%, mortality due to sepsis. Septic arthritis in the elderly is difficult to diagnose and carries a poor prognosis despite aggressive management.     

Melioidotic septic arthritis and its risk factors

BACKGROUND: Melioidotic septic arthritis is an infection caused by the gram-negative bacillus Burkholderia pseudomallei. It is commonly found in Northeast Thailand. The goal of our study was to identify specific characteristics of patients with melioidotic septic arthritis by comparing them with patients with non-melioidotic septic arthritis and to describe the results of treatment of melioidotic septic arthritis. METHODS: We conducted a retrospective study of seventy-seven patients with septic arthritis who were treated in our hospital over a period of four years. Twenty-five of the patients had melioidotic septic arthritis, and fifty-two had non-melioidotic septic arthritis. Univariate and multivariate analyses were conducted to identify the risk factors for melioidotic septic arthritis, and the clinical course of the twenty-five patients with melioidotic septic arthritis was followed until the infection resolved. RESULTS: Patients with melioidotic septic arthritis differed significantly (p = 0.002 ) from those with non-melioidotic septic arthritis with regard to the frequency of diabetes mellitus and of involvement of an upper-extremity joint. The odds ratio that melioidosis was the cause of the infection was 15.7 (95% confidence interval, 4.5 to 55.6) in a patient with diabetes mellitus and 4.51 (95% confidence interval, 1.04 to 19.65) in a patient with involvement of an upper-extremity joint. Twenty-two of the twenty-five patients with melioidotic septic arthritis responded to treatment, which consisted of six months of antibiotic therapy combined with needle aspiration, as well as surgical drainage of the affected joint when necessary (sixteen patients). CONCLUSIONS: A diagnosis of melioidotic septic arthritis should be considered when septic arthritis is seen in an individual who is indigenous to or has recently visited Southeast Asia. The infection is more likely to be melioidotic septic arthritis if it involves an upper-extremity joint and if the patient has diabetes mellitus.     

Syndromes with renal failure and shock

Renal failure occurs commonly in children with shock, coagulopathy and multi-organ failure. Successful management of these patients requires not only management of the renal failure, but recognition and treatment of the underlying process. In addition to common and wellrecognised causes of renal failure and shock, such as Gramnegative sepsis, there are a number of syndromes which are either less well recognised or confined to specific geographic locations. This article reviews the clinical and epidemiological features of the syndromes with shock and renal failure, focusing on the more recently recognised syndromes such as staphylococcal and streptococcal toxic shock syndrome, haemorrhagic shock and encephalopathy syndrome and viral haemorrhagic fevers.     

Septic lung and shock lung in man.

Two series of patients were studied by serial measurements of blood gas exchange and pulmonarmonary dysfunction and to evaluate the dangers of respiratory failure in post traumatic patients. There were 27 patients who had sustained profound hemorrhagic shock and massive blood replacement averaging 9.7 liters and 38 patients who suffered general peritonitis or other forms of fulminating nonthoracic sepsis. All were supported by endotrachael intubation and volume controlled ventilators. The overall mortality for the post shock patients without sepsis was 12% while in the septic patients it was 35%. The maximal pulmonary arteriovenous shunt encountered in the post hemorrhagic shock patients at 36 hours averaged 20 plus or minus 8% and was accompanied by high cardiac indices (average 5.1 plus or minus 1.3 L/M-2/min) but no significant rise of pulmonary arterial pressure or peak inspiratory pressure (PIP). Severe pulmonary dysfunction subsequently occurred only in those patients who later became septic. The studies on the septic patients were divided according to the magnitude of the cardiac indices (the high indices averaged 4.8 plus or minus 1.6L/M-2/min) and thelow indices averaged 1.9 plus or minus 1.0 L/M-2/min. In the former, the average maximal shunt of 30 plus or minus 6% was sustained for 4 or more days, accompanied by an elevation of PIP to 36 plus or minus 6 cm H2O and by Pa pressure of 28 plus or minus 5 mm Hg. The patients in low output septic shock usually had an associated bronchopneumonia and had an average venous admixture of 34 plus or minus 8% and PIP values of 41 plus or minus 8 cm H2O. The mean Pa pressure in this group was 29 plus or minus 6 mm Hg.     

Postoperative sepsis and septic shock after hip fracture surgery

IntroductionThere is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population.MethodsThe ACS-NSQIP (2015–2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality.ResultsOf 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37–3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26–13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%).ConclusionsThe incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.     

Causes of false-negative ultrasound scans in the diagnosis of septic arthritis of the hip in children

Ultrasound scans of the hip were carried out in 132 children with hip pain during an 18-month period to evaluate the hip for the presence of an effusion. Seventy-three of these patients were followed up long enough to ascertain the presence or absence of septic arthritis. The remaining 59 patients were discharged with diagnoses other than septic arthritis but could not be located to confirm the ultimate accuracy of the diagnosis. Four patients were initially determined to have no effusion but subsequently were diagnosed with septic arthritis (false-negative rate of 5%). Two of these patients had inadequate initial ultrasound examinations. Two children had ultrasound examinations that even on retrospective review did not reveal an effusion. Both of these children had had symptoms for <24 hours, and one had a contralateral hip effusion. The authors recommend using the negative results of an ultrasound scan as evidence of the absence of septic arthritis in children with caution when symptoms have been present for <24 hours or when bilateral disease exists.