Bacterial croup and toxic shock syndrome

Toxic shock syndrome in children: epidemiology, pathogenesis, and management

Toxic shock syndrome (TSS) is an acute, toxin-mediated illness, like endotoxic shock, and is characterized by fever, rash, hypotension, multiorgan involvement, and desquamation. TSS reflects the most severe form of the disease caused by Staphylococcus aureus and Streptococcus pyogenes. A case definition for staphylococcal TSS was well established in the early 1980s and helped in defining the epidemiology. Since the late 1980s, a resurgence of highly invasive streptococcal infections, including a toxic shock-like syndrome, was noted worldwide and a consensus case definition for streptococcal TSS was subsequently proposed in 1993. Both TSS and the toxic shock-like syndrome occur at a lower incidence in children than in adults. Changes in the manufacturing and use of tampons led to a decline in staphylococcal TSS over the past decade, while the incidence of nonmenstrual staphylococcal TSS increased. Nonmenstrual TSS and menstrual TSS are now reported with almost equal frequency. The incidence of streptococcal TSS remains constant after its resurgence, but varies with geographic location. Streptococcal TSS occurs most commonly following varicella or during the use of NSAIDs. Sites of infection in streptococcal TSS are much deeper than in staphylococcal TSS, such as infection caused by blunt trauma, and necrotizing fasciitis. Bacteremia is more common in streptococcal TSS than in staphylococcal TSS. Mortality associated with streptococcal TSS is 5-10% in children, much lower than in adults (30-80%), and is 3-5% for staphylococcal TSS in children.TSS is thought to be a superantigen-mediated disease. Toxins produced by staphylococci and streptococci act as superantigens that can activate the immune system by bypassing the usual antigen-mediated immune-response sequence. The host-pathogen interaction, virulence factors, and the absence or presence of host immunity determines the epidemiology, clinical syndrome, and outcome. Early recognition of this disease is important, because the clinical course is fulminant and the outcome depends on the prompt institution of therapy. Management of a child with TSS includes hemodynamic stabilization and appropriate antimicrobial therapy to eradicate the bacteria. Supportive therapy, aggressive fluid resuscitation, and vasopressors remain the main elements. An adjuvant therapeutic strategy may include agents that can block superantigens, such as intravenous immunoglobulin that contains superantigen neutralizing antibodies.

[Upper airway obstruction (foreign bodies excluded)]

Upper airway obstruction is a frequent cause of admission to the emergency department and the intensive care unit. Symptoms are mainly represented by dyspnea and stridor. Severity must be rapidly assessed to allow adapted treatment and avoid cardiac arrest and hypoxic encephalopathy. The possible etiologies are numerous, with acquired and congenital ones, but the majority is represented by laryngitis, lymphoid hypertrophy and laryngotracheomalacia. In case of respiratory failure, treatment must first establish airway patency with bag and mask ventilation, and then intubation. If vital prognosis is not threatened, biologic, radiologic or endoscopic examination can be performed to identify the cause of the obstruction and treat it.

Infraglottic and bronchial infections

Concerns over infraglottic and bronchial infections have been a source of anxiety and lost sleep for many children, parents, and physicians. The annual incidence of lower respiratory tract infections in children younger than 6 years old exceeds 5 million in the United States. Despite the frequency of these infections, the often common and nonspecific clinical symptomatology, variable severity, and changing epidemiology over time all have contributed to our understanding and misunderstanding of these disorders.

Upper airway obstruction

The airways in infants and children are anatomically different from adults, thus predisposing them to more acute upper airway obstruction. The causes of upper airway obstruction may be infective or non-infective. The presence of dysphonia, dysphagia, abnormal respiratory pattern, cough and abnormal posture suggests upper airway obstruction. The general management consist of supportive care with minimal invasive procedures. The specific treatment depends on the causes and is discussed in text.

Childhood exanthems. Old and new

Exanthems are a common cause of rashes in children. Several recent developments have sparked a renewed interest in this group of diseases, including the identification of parvovirus B19 and human herpesvirus 6 as the causative agents of erythema infectiosum and roseola infantum. The resurgence of measles as a childhood exanthem has caused a re-examination of current immunization practices. The most common and clinically significant exanthems are discussed, with an emphasis on new findings, origins, clinical manifestations, differential diagnosis, and management.

Bacterial tracheitis

Bacterial tracheitis is the term used to describe a severe infraglottic infection characterized by toxicity, brassy cough, inspiratory stridor, subglottic oedema and the presence of copious mucopurulent secretions in the trachea. It is an uncommon condition that requires prompt diagnosis and intensive medical therapy if significant morbidity and mortality are to be avoided. Since the condition was first described in 1979 approximately one hundred cases have been reported. In this paper we present four children with bacterial tracheitis to add to the current literature. Interestingly, one child was admitted on two separate occasions with the disease, an event not previously recorded. All patients underwent endoscopy which revealed findings typical of bacterial tracheitis in each case. None required tracheostomy though three required nasotracheal intubation. Post-endoscopy all were managed in the Intensive Care Unit. There were no fatalities or significant morbidity. The average duration of hospitalization was seven days.