Toxic Shock Syndrome in Children

Toxic shock syndrome (TSS), a severe, acute life-threatening condition, mostly affects healthy children. Exotoxins are primarily produced by Staphylococcus aureus (TSST-1) and group-A beta-hemolytic streptococci, which cause this condition. These exotoxins are superantigens that begin nonspecific, polyclonal T-cell activation and an uncontrolled immune response causing cytokine storm. These cause clinical manifestations of TSS, like high-grade fever, erythroderma, gastrointestinal symptoms, and capillary leak that lead to hypotension with consequential multiorgan failure. Children are typically more sensitive to TSS as they don't have protective antibodies against the causative toxins.

The diagnosis primarily relies on clinical manifestations, with some laboratory parameters indicating organ dysfunction without alternative etiologies. Unfortunately, no specific diagnostic test exists to differentiate TSS from diseases with identical clinical features. However, the common differentials are sepsis/septic shock, Kawasaki illness, drug reactions, COVID-19-associated multisystem inflammatory syndrome, meningococcal and rickettsial infections, leptospirosis, dengue fever, and enteric fever. 

There isn't strong evidence to back the use of IVIG in TSS, particularly staphylococcal TSS. A systematic review that included five studies suggested a survival benefit of IVIG in clindamycin-treated patients with streptococcal TSS. IVIG may be given to patients with severe staphylococcal TSS who are resistant to other therapeutic measures. However, more clarity is needed regarding the use of IVIG in TSS.

Takia L, Lodha R. Toxic Shock Syndrome: A Diagnostic and Therapeutic Challenge!. Indian J Pediatr. 2023;90:321–322. https://doi.org/10.1007/s12098-023-04478-z