A 3yo M no sig PMH, IUTD, comes into your ED with complaint of 3 days of fevers, diffuse rash worst on the R hip, mild limp, N/V, no urine output today, and lethargy. On exam, found to be febrile to 40.1, tachy to 197, BP 90s/50s, sat 96%. Irritable but awake. HENT with bilateral conjunctival erythema (limbic sparing), dry cracked lips, red beefy tongue. Neck exam with shoddy LAD on the left.  Diffuse erythematous (sunburn-like), maculopapular rash, worse on trunk and over R hip, no petechiae. Has decreased ROM 2/2 pain on R hip; mild ttp over R hip, all other joints normal.

Labs sent and notable for lactate of 3.6, NA 129, BUN/Cr of 36/1.4, Tbili 2.2, AST/ALT 81/51,Trop of 0.3

Pt becomes hypotensive to the 50s systolic. Ends up requiring pressors as hypotensive despite fluids boluses x3 and no increase in urine output. Stops bearing weight on the R leg.

Whats going on? 

This case was concerning for TSS. He was started on vancomycin and clindamycin (for the anti-toxin effect). Echo was normal.  Later MRI showed osteo of the R femoral neck. BCx grew MSSA.  The patient had a 2 week admission initially in the PICU, then the floors, and ended up doing well.

In this case, osteomyelitis was the initial infection that then led to Toxic Shock Syndrome

Majority caused by Staph aureus or Strep pyogenes (AKA group A Strep) as a toxin-mediated disease. These toxins act as superantigens, activating large numbers of T cells leading to the massive release of cytokines (e.g. interleukin (IL)-1, IL2, Tumor Necrosis Factor (TNF)-alpha, TNF-beta and interferon-gamma)

Diagnosis is clinical, only 5% will grow out a culture, and this obviously won’t be helping in the ED setting

Major criteria for diagnosis of staph TSS: fever, SBP <5th percentile for age (or < 90 mm Hg in adults) and an erythrodermic rash with subsequent desquamation. Minor criteria: involvement of >3 of: GI tract, muscles, mucous membranes, renal system, hepatic system, blood, or central nervous system. Also, no other alternative diagnosis.

Clinical Pearls:

In pediatric TSS, 50% present under 2 yrs of age, so keep it on your differential

50% of cases present normotensive and become hypotensive within 4 hours – keep an eye on their vital signs

If you are considering Kawasaki’s in a shock-y patient, but don’t see any signs of cardiac involvement, consider TSS as the diagnosis! They can present very similarly. If Kawasaki’s presents with shock, they must have carditis.

In very sick patients – consider steroids or IVIG, though neither has a ton of evidence, they can help in selected patients with overall mortality

***Thanks to our Pediatric EM fellow Dr. Sanders for a great morning report***