Infection with Staphylococcus aureus producing toxic shock syndrome (TSS) toxin-1 without TSS

Relevant findings are reported in an 8-year-old boy with skin infection due to Staphylococcus aureus producing toxic shock syndrome toxin-1 without shock but with an increase in antibody titre against the toxin.Abbreviations anti-TSST-1 antibody against toxic shock syndrome toxin 1 - TSS toxic shock syndrome - TSST-1 toxic shock syndrome toxin-1     

Early diagnosis of staphylococcal toxic shock syndrome by detection of the TSST-1 Vbeta signature in peripheral blood of a 12-year-old boy

We report the case of a 12-year-old boy who developed staphylococcal toxic shock syndrome associated with S. aureus pharyngeal colonization or infection. The diagnosis was rapidly confirmed by detecting the Vbeta signature of the toxic shock syndrome toxin-1 in peripheral blood, based on transient T cell depletion rapidly followed by massive expansion of Vbeta 2-positive T cells.     

Possible relationship between streptococcal pyrogenic exotoxin A and Kawasaki syndrome in patients older than six months of age

BACKGROUND: We previously investigated antibody titers against four kinds of superantigens [streptococcal pyrogenic exotoxin A (SPEA), streptococcal pyrogenic exotoxin C, toxic shock syndrome toxin-1 and staphylococcal enterotoxin B] in patients with Kawasaki syndrome (KS) younger than 6 months of age and reported a relationship between toxic shock syndrome toxin-1 and KS patients. In this study we have investigated antibody titers in KS patients older than 6 months of age. METHODS: Serum of 81 patients with KS older than 6 months of age, before intravenous gamma-globulin therapy, and 88 normal age-matched children were used in this study. The IgG antibody titers against four kinds of superantigens were measured with an enzyme-linked immunosorbent assay. RESULTS: The KS patients showed significantly elevated mean SPEA titer (P = 0.006) and significantly higher incidence of high SPEA (P = 0.0024) compared with the controls. The SPEA titer in KS patients showed a significant positive correlation with the number of days from onset of illness (P = 0.0002). CONCLUSIONS: The elevated antibody titer against superantigens of KS patients older than 6 months of age was different from that of KS patients younger than 6 months of age. Our results suggest that KS patients' exposure to SPEA occurred a few weeks before the onset of KS. SPEA may be one of the possible etiologic agents of KS among patients older than 6 months of age in Kagoshima, Japan.     

Neonatal toxic shock syndrome-like exanthematous disease (NTED)

The author and colleagues recently discovered an emerging neonatal infectious disease: neonatal toxic shock syndrome-like exanthematous disease (NTED), which is induced by the superantigen toxic shock syndrome toxin-1 (TSST-1), produced by methicillin-resistant Staphylococcus aureus (MRSA). The massively expanded Vbeta2+ T cells were rapidly deleted in the peripheral blood of patients with NTED. A marked depletion of Vbeta2+ T cells was also observed in the peripheral blood before the expansion of these T cells. Anergy is specifically induced in the TSST-1 reactive T cells of patients with NTED. Rapid recovery from NTED without complications is expected to be related to the induction of immunologic tolerance in neonatal patients. Anti-TSST-1 IgG antibody of maternal origin was found to play a protective role in preventing the development of NTED. The number of hospitals that have experience caring for patients with NTED has increased threefold in the past 5 years. Most MRSA isolates from neonatal intensive care units in Japan were found to be a single clone of coagulase type II and to possess TSST-1 and staphylococcal enterotoxin C genes. The timing and increased incidence of NTED suggest the emergence of a new MRSA clone. By recognizing that TSST-1 can induce NTED, healthcare providers may give increased attention to this disease in neonatal wards.     

Toxic shock syndrome associated with poison oak dermatitis

Toxic shock syndrome commonly occurs in menstruating women, but it is known to be associated with a variety of staphylococcal infections. We report a case of nonmenstrual toxic shock syndrome in an 11-year-old male who presented with altered consciousness and infected poison oak dermatitis of the feet. This is the first reported case of toxic shock syndrome associated with poison oak dermatitis. The signs and symptoms, laboratory findings, and treatment of toxic shock syndrome are reviewed.     

Necrotizing haemorrhagic pneumonia proves fatal in an immunocompetent child due to Panton-Valentine Leucocidin, toxic shock syndrome toxins 1 and 2 and enterotoxin C-producing Staphylococcus aureus

Panton-Valentine leucocidin (PVL) toxin-producing strains of Staphylococcus aureus (S. aureus) are associated with skin abscesses and furunculosis, with necrotizing pneumonia being a relatively rare problem. Here, we describe a fatal case of necrotizing pneumonia in a 14-year-old child who presented initially with sore throat and pyrexia. He deteriorated rapidly, developing hypotension, multiple organ failure and purpura fulminans. S. aureus was isolated from the tracheal aspirate, which was found to be positive for PVL, toxic shock syndrome toxins (TSST) 1 and 2 and staphylococcal enterotoxin C (SEC). It was postulated that purpura fulminans and toxic shock syndrome were a result of the abovementioned exotoxins. CONCLUSION: This case highlights the emergence of PVL-positive community-acquired S. aureus infection and association of purpura fulminans with superantigens. Practitioners should be aware of this illness in order to initiate appropriate treatment.     

Necrotizing haemorrhagic pneumonia proves fatal in an immunocompetent child due to Panton–Valentine Leucocidin, toxic shock syndrome toxins 1 and 2 and enterotoxin C-producing Staphylococcus aureus

Panton–Valentine leucocidin (PVL) toxin-producing strains of Staphylococcus aureus ( S. aureus ) are associated with skin abscesses and furunculosis, with necrotizing pneumonia being a relatively rare problem. Here, we describe a fatal case of necrotizing pneumonia in a 14-year-old child who presented initially with sore throat and pyrexia. He deteriorated rapidly, developing hypotension, multiple organ failure and purpura fulminans. S. aureus was isolated from the tracheal aspirate, which was found to be positive for PVL, toxic shock syndrome toxins (TSST) 1 and 2 and staphylococcal enterotoxin C (SEC). It was postulated that purpura fulminans and toxic shock syndrome were a result of the abovementioned exotoxins.
Conclusion: This case highlights the emergence of PVL-positive community-acquired S. aureus infection and association of purpura fulminans with superantigens. Practitioners should be aware of this illness in order to initiate appropriate treatment.     

A severe case of neonatal toxic shock syndrome-like exanthematous disease with superantigen-induced high T cell response

Most newborn patients with a neonatal type of toxic shock syndrome (TSS), called neonatal TSS-like exanthematous disease (NTED), exhibit mild clinical symptoms. We present the case of a patient with NTED who exhibited exceptionally severe clinical symptoms and an adult-type T cell response to the causative toxin TSS toxin-1.     

Bacterial croup and toxic shock syndrome

An 8-year-old boy with bacterial tracheitis, treated by endotracheal intubation, humidification, airway toilet and antibiotics, experienced a toxic shock syndrome on the day after his admission. The course was favourable. Staphylococcus aureus was isolated from tracheal secretions. Bacterial tracheitis is an infrequent cause of non-menstrual toxic shock syndrome. The diagnosis of bacterial tracheitis should be suspected in a child with toxicity and croup who is not responding to the usual therapy. Endoscopy should be performed allowing for removal of the secretions. The maintenance of a clear airway is the main purpose of the treatment.Abbreviations TSS toxic shock syndrome - CNS central nervous system - CRP C-reactive protein - ICU intensive care unit     

Pediatric streptococcal toxic shock syndrome.

Two children who presented with fever, rash, and hypotension were found to have group A beta hemolytic streptococcal toxic shock syndrome. These cases are reported to remind physicians who care for acutely ill children that exotoxin-producing streptococci can produce clinical features and multisystem failure similar to staphylococcal toxic shock syndrome.     

Toxic shock syndrome

The authors present two children who had fever ≥38.9°C, diffuse rash, hypotension, deranged renal and hepatic functions, disseminated intravascular coagulation, altered sensorium and inflamed oral mucosa. They responded to fluids, inotropes, antibiotics and intravenous immunoglobulin (2 g/kg). Desquamation particularly of palms and soles and periungal region was noted 1 to 2 weeks after onset of illness. These features were consistent with the diagnosis of staphylococcal toxic shock syndrome (TSS). The cases highlight that TSS is very much with us and can mimic a variety of other diseases. Early recognition, and aggressive antimicrobial supportive and IVIG therapy cover can ensure complete recovery     

Maternal-fetal staphylococcal toxic shock syndrome with chorioamniotitis]

We report a rare case of mother-infant pair with Staphylococcal Toxic Shock Syndrome (TSS). A term neonate was born by caesarean section for maternal septic syndrome during per-partum. He presented with respiratory distress complicated by pulmonary hypertension, skin rash, and multiple organ system involvement. Staphylococcus aureus was isolated from placenta, surface swabs and gastric aspirate. He received adapted antibiotics, respiratory support by high frequency ventilation and NO. The mother had shock, skin rash and inflammatory syndrome. Outcome was good in both cases. The isolate produced enterotoxin C and L. Shock, exanthematous disease and multi-organ involvement complicating a staphylococcal infection in neonate must lead to suspect a TSS.     

Toxic shock syndrome in a neonate

We report an unusual case of toxic shock syndrome in a 4-day-old baby, with mucosal isolates of Staphylococcus aureus (SEC, G, and I) and group G streptococcus. Treatment involved intravenous immunoglobulin and antibiotics. This case highlights the difficulties associated with the diagnosis and treatment of this condition in neonates.     

Bullous impetigo: a rare presentation in fulminant streptococcal toxic shock syndrome

Since the mid-1980s, an increase in incidence of invasive disease caused by group A streptococci has been noted among adults and children. The characteristic clinical and laboratory features of the streptococcal toxic shock syndrome include deep-seated infection associated with shock, skin manifestation, and multiorgan failure. However, bullous impetigo is invariably considered to be a staphylococcal disease. Staphylococcus aureus produces an epidermolytic toxin, assumed to be the cause of bullous formation in the skin. Here, we present a case of bullous impetigo in an infant with streptococcal toxic shock syndrome. This is a rare presentation of bullous impetigo caused by group A streptococcus.     

Toxic shock syndrome in a 14-year-old girl

The toxic shock syndrome in a 14-year old girl is described. This syndrome occurs most frequently - but not exclusively - in the teens and young women during the first days of menstruation, if tampons are used. The patients are acutely ill with high fever, diarrhea and/or vomiting, with a rash, with loss of consciousness, and signs of shock (occasionally shock lung syndrome and renal insufficiency). During convalescence desquamation of hands and feet shows up. Patients with much less severe symptoms have been seen. The primary lesion is a local infection (e.g. vaginitis) with staphylococcus aureus, the symptoms being caused by staphylococcal toxins. Early recognition and immediate therapy are important for a better prognosis. The therapy consists of removal of the tampon, i.v. fluids including albumin, and the administration of a beta-lactamase-resistant antibiotic.     

Genetic basis of neonatal methicillin-resistant Staphylococcus aureus in Japan

Methicillin-resistant Staphylococcus aureus (MRSA) is still one of major problems of drug-resistant microorganisms and healthcare-acquired infections. Methicillin-resistant Staphylococcus aureus is highly prevalent in patients in neonatal intensive care units (NICU) in Japan. The most predominant MRSA in NICU is multidrug resistant and produces superantigenic exotoxin, toxic shock syndrome toxin-1 (TSST-1) and staphylococcal enterotoxin C (SEC). These predominant MRSA strains belong to coagulase type II, SCCmec type II, mecA-Tn554 polymorph type I-A and show closely related pulse field gel electrophoresis types. The dissemination of MRSA is wide, and there is a pandemic distribution of a single MRSA clone in the NICU of Japan. Since 1992, the nationwide spread of this clone has also led to the development of a new neonatal disease known as neonatal toxic shock-like exanthematous disease (NTED), which is caused by overactivation of vbeta2+ T cells induced by TSST-1. The spread of MRSA in NICU in Japan has been attributed to overcrowding, high rates of extremely low birthweight babies, understaffing, low control measures of infection and overuse of antibiotics. The environment of NICU and infection control intervention should be improved and a new strategy for control like vaccination or probiotics is required.     

Toxic shock syndrome and streptococcal myositis: three case reports

Group A streptococcal (GAS) infection is the most common cause of bacterial pharyngitis and has an important role in the pathogenesis of post-infective phenomena including rheumatic fever and glomerulonephritis. Mortality from GAS is uncommon, particularly in the paediatric population. Toxic shock syndrome reflects the most severe form of GAS-related disease and is often associated with fasciitis or myositis. CONCLUSION: We present three cases of toxic shock syndrome secondary to (GAS) myositis demonstrating the importance of early recognition and provision of intensive care management.     

Toxic shock syndrome

We report about a one year old girl with toxic shock syndrome (TSS), which was confirmed by a significant rise of TSST-1 titers. In addition to known manifestations of TSS, to our knowledge this is the first report about development of polyserositis in this disease. Tumor necrosis factor (TNF) was elevated at initial evaluation and fell under treatment with cortisone. This finding is in contrast to in-vitro observations. We believe that the use of cortisone in TSS warrants further investigation.     

Streptococcal toxic shock syndrome in children without skin and soft tissue infection: report of four cases

Streptococcal toxic shock syndrome is a fulminant, highly fatal disease characterized by evidence of group A beta-haemolytic streptococcus infection and early shock with consecutive organ failure. In adults, affected individuals usually have preceding skin or soft tissue infection. However, in paediatric patients, except for varicella, the background focus is usually respiratory tract infection, and early diagnosis of streptococcal toxic shock syndrome in such patients is difficult. We report four previously healthy children with streptococcal toxic shock syndrome. Pharyngitis was identified in three cases. All of them had constitutional symptoms such as fever, vomiting, diarrhoea, abdominal pain and physical findings of tachycardia and diffuse abdominal tenderness, but no concomitant skin infection. CONCLUSION: Streptococcal toxic shock syndrome should be considered in paediatric patients with fever, vomiting, diarrhoea, abdominal pain and early shock. Early diagnosis, prompt initiation of antibiotics and aggressive fluid therapy are lifesaving for such patients.     

Toxic shock syndrome in 2 girls with pharyngeal infection and wound infection

In 1981, a 13 year old girl died of her shock lung. She had been admitted with the classical toxic shock syndrome then still unknown to us. Staphylococcus aureus had been cultured from a pharyngeal swab. But even in 1987, it took us 48 hours to correctly diagnose the toxic shock syndrome in a 17 year old girl. The diagnosis became evident when she was found to have a staphylococcus aureus wound infection after a surgical procedure. For pediatricians, it is crucial to know this syndrome well. Not only menstruating girls using tampons, but also quite young children can acquire this disease. Quick diagnosis and prompt institution of the correct therapy can be life saving.