VOL: 99, ISSUE: 05, PAGE NO: 26
Colin A. Michie, MA, FRCPCH, FLS is consultant senior lecturer in paediatrics, and honorary consultant, Public Health Laboratories Service
Varsha Shah, RSCN, is sister in paediatrics, Ealing Hospital NHS Trust
Toxic shock syndrome is a rare and potentially fatal condition which may develop in individuals of all ages. Although comparatively rare, A&E nurses will probably be the first to meet a patient with this condition. Some knowledge of TSS is important as early diagnosis and treatment may be life-saving.
It is rare in children under six and is less common in Afro-Caribbean races. Higher rates of TSS in the USA, during the 1980s, were associated with a specific type of vaginal tampon or certain surgical packs following nasal surgery (Parsonnet, 1996). This pattern was not seen in the UK: the Public Health Laboratories Services recorded up to 15 cases a year, with the greatest number in 1990.
A child with a burn or scald involving less than five per cent of body surface area usually recovers without incident. One in a 1000 of such cases will develop fever and malaise two to three days later. This may progress to a rash, conjunctival infection and diarrhoea within 24 hours. On examination the child will have tachycardia and hypotension. The hypotension is progressive and often unresponsive to intravenous resuscitation. The first problems nursing staff or parents might notice are fever and drowsiness, perhaps a rash, and diarrhoea. The toxins stimulate immune cells leading to the release of cytokines, which cause fever and tissue damage.
A series of 68 TSS cases in the UK, compiled by the authors between 1990 and 2000, sheds some light on who diagnoses TSS. Of this group, 43 cases were burn or trauma-related. The median period of fever before diagnosis was four days (range two to 12 days). Twenty cases were diagnosed by primary carers before referral and 11 were diagnosed in A&E. Burns-related cases were missed at initial presentation more often than menstrually related cases. Nursing staff first made six of the diagnoses in A&E and made additional diagnoses on the wards.
The principles of treatment are to block the effects of the toxin and remove bacteria that make more toxin, while supporting the patient (Dinges, 2000; Mellish, 1992). This will involve support for the cardiovascular, renal and respiratory systems as with any other patient with shock. In practice providing mask oxygen, intravenous resuscitation, intravenous immunoglobulin and clindamycin will be sufficient. Clindamycin is the preferred antibiotic because it blocks further toxin production by bacteria. Intravenous immunoglobulin neutralises toxins and their effects and can result in the patient’s rapid improvement.
The Toxic Shock Syndrome Information Service