The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature

Streptococcal Toxic Shock Syndrome: A Case Series Emphasizing the Urgency of Recognition and Tailored Treatment

BACKGROUND

Streptococcal toxic shock syndrome (TSS) is a rare but lethal condition associated with Streptococcus Pyogenes Group A (GAS). With rising incidence and high mortality, timely recognition and management are crucial. This case series presents two adult TSS cases caused by invasive GAS, highlighting the importance of early identification and multidisciplinary management.

CASE PRESENTATIONS

The first case involves a 42-year-old male who presented with fever, dizziness, and a tender, erythematous olecranon following an elbow laceration. Despite negative imaging for necrotizing fasciitis, a positive throat swab for GAS prompted immediate broad-spectrum antibiotics and aggressive resuscitation. Clindamycin and intravenous immunoglobulin were administered. The patient developed TSS and acute kidney injury, requiring intensive care and hemodialysis. The second case features a previously healthy 43-year-old female presenting with systemic symptoms and a rash, without trauma history. Positive GAS blood cultures confirmed TSS, leading to similar management and subsequent renal complications requiring hemodialysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases highlight the evolving epidemiology of invasive GAS infections and the associated risk of TSS. Early identification and appropriate tailored treatment are essential to reduce morbidity and mortality, especially given the recent surge in invasive GAS. Clinical vigilance for skin changes and thorough laboratory investigations, including non-sterile site cultures, are critical. Early identification enables the use of adjunctive treatments like clindamycin and IVIG, and facilitates appropriate de-escalation of antibiotics. Prompt consultation with infectious disease, intensive care, and surgical teams is necessary to ensure optimal treatment.

Incidence and Risk Factors for Toxic Shock Syndrome After Endoscopic Sinus Surgery: A Systematic Review

OBJECTIVE

Toxic shock syndrome (TSS) is a rare but serious complication after sinonasal surgery and a commonly cited consideration for prescribing antibiotics when nasal packing or stents are placed. Most reports are limited to case reports or small series. The aim of this systematic review was to describe the incidence, risk factors, and clinical course of patients who developed TSS as a complication of endoscopic sinus surgery (ESS) and/or septoplasty.

DATA SOURCES

A systematic review was conducted using MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library databases.

REVIEW METHODS

Eligibility criteria were patients of any age who developed TSS as a complication of ESS and/or septoplasty.

RESULTS

Twenty-five studies were included in the final review. Seventy cases were identified over 38 years (1982-2020). The pooled incidence of TSS after sinonasal surgery was 0.0003 (0.0002-0.0004, 95% confidence interval, CI) or 30 per 100,000 persons. Among 33 patients with single-subject data, mean age was 33.8 years (29.73-37.87, 95% CI). Seventeen (51.5%) patients had nasal packing, 3 (9.1%) had stents, 5 (15.2%) had both, 7 (21.2%) had none. Fourteen (42.4%) patients had nonabsorbable packing and 5 (15.2%) had absorbable packing. Sixteen (48%) patients received peri-operative antibiotics. Thirty-two (97%) patients had full recovery.

CONCLUSION

The incidence of TSS after sinonasal surgery is very rare. TSS can occur with and without nasal packing and prophylactic antibiotics were not protective. Outcomes were favorable with appropriate recognition and management. Further study is needed to determine which patients are most at risk for TSS.

The Epidemiology of Pediatric Thermal Injury-associated Toxic Shock Syndrome: A Systematic Review

Thermal injury-associated toxic shock syndrome (TSS) is a life-threatening condition that can occur in children following burn injuries. The objective of this study was to describe the clinical manifestations, treatment, and outcomes of children who experienced TSS following a thermal injury. Additionally, the existing literature was systematically examined and published cases of pediatric TSS occurring after burns were compiled. In June 2023, without regard for time constraints, articles that met the criteria were searched across several electronic databases. The inclusion criteria were English-language publications, pediatric patients, and reported outcomes of interest for clinical questions. Due to the heterogeneity of the included publications and the lack of data in an appropriate format, a meta-analysis was not feasible. Our research identified 23 studies published between 1980 and 2023, including 72 cases (from multiple countries) that met the inclusion criteria. Of the 72 patients with thermal injuries complicated by TSS, 53 (73.6%) children survived, 6 (8.3%) died, and for 13 (18%) cases, the outcome was not documented. Our systematic review highlights the rarity, severity, and complexity of pediatric thermal injury-associated TSS. Key findings from the review indicate that pediatric thermal injury-associated TSS carries a high mortality rate and significant morbidity. By increasing awareness, improving diagnostic accuracy, and optimizing treatment strategies, healthcare professionals can improve patient outcomes in this challenging condition.

Deciphering the Etiologies of Adult Erythroderma: An Updated Guide to Presentations, Diagnostic Tools, Pathophysiologies, and Treatments

Erythroderma, an inflammatory skin condition characterized by widespread erythema with variable degrees of exfoliation, pustulation, or vesiculobullous formation, is associated with high morbidity and mortality. Determining the underlying cause of erythroderma frequently presents a diagnostic challenge, which may contribute to the condition's relatively poor prognosis. This review covers the clinical presentation, pathophysiology, diagnosis, and treatment of erythroderma. It discusses similarities and differences among the many underlying etiologies of the condition and differences between erythrodermic and non-erythrodermic presentations of the same dermatosis. Finally, this article explores current research that may provide future tools in the diagnosis and management of erythroderma.

Dermatologic manifestations of zoonotic diseases transmitted by dogs: "Spot" could give you spots

The bond between humans and dogs is precious and has been treasured since ancient times. Dog ownership is linked to numerous health benefits, such as increased physical activity and social functioning and decreased depression and cardiovascular events. However, dogs can transmit zoonotic diseases to humans, many of which present with cutaneous findings. This review summarizes the dermatologic manifestations, transmission routes, diagnosis, and treatment of zoonotic diseases transmitted by dogs, including vector-borne, bacterial, viral, fungal, and parasitic infections. This review emphasizes the significance of clinicians obtaining a comprehensive exposure history when patients exhibit a rash of unknown origin. Such an approach can provide valuable epidemiological clues related to diagnosing a zoonotic disease transmitted by a pet dog. Furthermore, identifying the dog as an infection source and subsequent veterinary treatment can help prevent recurrent infections in dermatologic patients.

Long-term outcomes of patients with toxic shock syndrome: A matched cohort study

OBJECTIVES

We examined long-term outcomes of toxic shock syndrome.

METHODS

We conducted a matched cohort study of 630 patients with toxic shock syndrome and 5009 healthy controls between 2006 and 2021 in Quebec, Canada. Outcomes included hospitalization for renal, cardiovascular, hepatic, and other morbidity during 15 years of follow-up. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the risk of these outcomes over time, comparing patients with toxic shock syndrome relative to matched controls.

RESULTS

Compared with healthy controls, rehospitalization rates at 15 years were higher for men with toxic shock syndrome (52.0 vs 30.0 per 100) but not for women (38.7 vs 45.6 per 100). In men, toxic shock syndrome was associated with an elevated risk of renal (HR 17.43, 95% CI 6.35-47.82), cardiovascular (HR 2.57; 95% CI 1.52-4.34), and hepatic hospitalization (HR 19.83, 95% CI 4.72-83.34). In women, toxic shock syndrome was associated with renal hospitalization (HR 4.71, 95% CI 1.94-11.45). Streptococcal toxic shock was associated with a greater risk of rehospitalization than staphylococcal toxic shock.

CONCLUSIONS

Toxic shock syndrome is associated with rehospitalization up to 15 years later, especially in men. These patients may benefit from continued follow-up to prevent long-term morbidity.

Tofacitinib Treatment Suppresses CD4+ T-Cell Activation and Th1 Response, Contributing to Protection against Staphylococcal Toxic Shock

Staphylococcal toxic shock syndrome (STSS) is a rare, yet potentially fatal disease caused by Staphylococcus aureus (S. aureus) enterotoxins, known as superantigens, which trigger an intense immune response. Our previous study demonstrated the protective effect of tofacitinib against murine toxin-induced shock and a beneficial effect against S. aureus sepsis. In the current study, we examined the effects of tofacitinib on T-cell response in peripheral blood using a mouse model of enterotoxin-induced shock. Our data revealed that tofacitinib suppresses the activation of both CD4+ and CD8+ T cells in peripheral blood. Furthermore, both gene and protein levels of Th1 cytokines were downregulated by tofacitinib treatment in mice with enterotoxin-induced shock. Importantly, we demonstrated that CD4+ cells, but not CD8+ cells, are pathogenic in mice with enterotoxin-induced shock. In conclusion, our findings suggest that tofacitinib treatment suppresses CD4+ T-cell activation and Th1 response, thereby aiding in protection against staphylococcal toxic shock in mice. This insight may guide the future development of novel therapies for STSS.

Unilateral lymphadenitis caused by community-associated methicillin-resistant Staphylococcus aureus ST834 strain

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a global concern, primarily as a cause of skin and soft tissue infections, particularly in young people. Here, we describe a case of unilateral multiple lymphadenitis caused by the CA-MRSA sequence type (ST) 834 strain. A previously healthy 15-year-old girl was referred to our hospital with fever and swollen lymph nodes in the right axillary, cubital, and groin regions. Imaging examinations revealed enlargement of the lymph nodes in these areas but no swelling in any other lymph nodes. The patient had self-destructive lymph nodes in her groin. MRSA was detected in all swollen lymph node samples. Antimicrobial susceptibility tests showed that MRSA was susceptible to clindamycin and levofloxacin, leading to the suspicion of CA-MRSA. Genetic analysis revealed that all strains were ST834 and carried the staphylococcal cassette chromosome mec IV and the toxic shock syndrome toxin-1 gene but not the Panton-Valentine leukocidin gene. The patient was treated with linezolid followed by oral clindamycin. This was a rare case of unilateral multiple lymphadenitis caused by ST834 CA-MRSA. Although ST834 strains are rarely reported, lymphadenitis has been frequently reported and is considered more likely to cause lymphadenitis than other CA-MRSA strains.

Fever and Rash

Infectious causes of fever and rash pose a diagnostic challenge for the emergency provider. It is often difficult to discern rashes associated with rapidly progressive and life-threatening infections from benign exanthems, which comprise the majority of rashes seen in the emergency department. Physicians must also consider serious noninfectious causes of fever and rash. A correct diagnosis depends on an exhaustive history and head-to-toe skin examination as most emergent causes of fever and rash remain clinical diagnoses. A provisional diagnosis and immediate treatment with antimicrobials and supportive care are usually required prior to the return of confirmatory laboratory testing.

Toxic Shock Syndrome as an Unexpected Complication in Outpatient Pediatric Burn Treatment: A Chart Review

Background: Minor burn injuries in children affecting less than 10% of total body surface area (TBSA) are often successfully managed in the outpatient setting, however it is important to recognize they can be associated with serious sequelae such as toxic shock syndrome (TSS). Methods: We conducted a retrospective chart review at a tertiary-level pediatric hospital between May 2012 and May 2022 to identify pediatric patients diagnosed with TSS following minor burn injuries. Data collected included: patient demographics, burn characteristics, TSS symptoms, and management. Data was analyzed using descriptive statistics. Results: During the study period, 3706 patients with minor burns were treated as outpatients, of which 6 patients developed TSS. Ages ranged from 12 to 36 months, and half were male. Most injuries were scalds (n = 4) or contact injuries (n = 2), involving 1% to 3% TBSA partial-thickness burns. Early symptoms of TSS included vomiting (n = 6) and fever (n = 5), and later, hypotension (n = 5). Hospital admission for TSS occurred 1 to 6 days post-injury. Four of the 6 patients required ICU care, with 2 of them requiring fluid resuscitation and 2 receiving IVIg. The clinical course of 2 patients was complicated by deep vein thrombosis, with 1 patient developing a septic ileus as a secondary infection. All patients recovered and were discharged home after 3 to 9 days. Conclusion: We highlight the rare complication of TSS following minor burns in children. Providers should be vigilant for early symptoms of TSS like fever, vomiting, and hypotension. Further research to identify at-risk patients and preventative treatment would be beneficial.

Systemic immune response of burns from the acute to chronic phase

Immune responses that occur following burn injury comprise a series of reactions that are activated in response to damaged autologous tissues, followed by removal of damaged tissues and foreign pathogens such as invading bacteria, and tissue repair. These immune responses are considered to be programmed in living organisms. Developments of modern medicine have led to the saving of burned patients who could not be cured previously; however, the programmed response is no longer able to keep up, and various problems have arisen. This paper describes the mechanism of immune response specific to burn injury and the emerging concept of persistent inflammation, immunosuppression, and catabolism syndrome.

Toxic Shock Syndrome: Eighteen Years of Experience in a Pediatric Intensive Care Unit

Introduction Toxic shock syndrome (TSS) is a life-threatening disease usually caused by a Staphylococcus aureus or group Aβ-hemolytic Streptococcus infection. Methods In this retrospective study, we included patients with TSS admitted to a tertiary hospital's pediatric intensive care unit (PICU) over the last 18 years. We compared the staphylococcal TSS (Staph-TSS) and streptococcal TSS (Strep-TSS) groups. Results We included 17 patients (64.7% male), with a median age of 6.1 years (3.0 years for streptococcal TSS versus 13.3 years for staphylococcal TSS, p = 0.040), a median of 3.0 days from symptom onset to diagnosis, and a median of 6.0 days of hospitalization. Ten patients met the Centers for Disease Control and Prevention (CDC) criteria for staphylococcal TSS (one menstrual-related) and seven met the criteria for streptococcal TSS (four of them occurring since the COVID-19 pandemic was declared). Fifteen patients had identified risk factors, primarily cutaneous lesions (29.4%). In 15 patients, at least three organs or systems were affected, with fever, rash, and hypotension as universal findings. Mucous membrane hyperemia was present in 16 patients, gastrointestinal symptoms in 14 patients, and desquamation in nine. Muscular involvement was present in seven patients, all with staphylococcal TSS (p = 0.010). All patients received two or more antibiotics, including a protein synthesis inhibitor (except for one), and required fluid resuscitation and vasoactive amines (median three days). Six patients needed invasive mechanical ventilation (median seven days). Albumin infusion was necessary in six patients, significantly more frequently in patients with streptococcal TSS (p = 0.035). Two patients with staphylococcal TSS died, while the seven patients with streptococcal TSS survived hospital discharge. There were no recurrent cases. Conclusions Our study revealed TSS severity and multiorgan involvement, emphasizing the importance of early diagnosis and intervention. Risk factors were prevalent, and we noted an increased frequency of group A streptococcal (GAS) TSS post-COVID-19 pandemic.

Evaluating antibiotic regimens for streptococcal toxic shock syndrome in children

INTRODUCTION

Streptococcal toxic shock syndrome (STSS) is a severe consequence of infections from Streptococcus pyogenes. The early identification and timely intervention with appropriate anti-infective agents are pivotal for managing pediatric STSS. This study evaluates the effectiveness of various treatment regimens for STSS in children.

METHODS

Clinical data of children with STSS resulting from β-hemolytic streptococcal infections in two hospitals were retrospectively analyzed from January 2009 to April 2023. Additionally, literature from the China National Knowledge Infrastructure on pediatric STSS was examined. Antimicrobial treatments were categorized into four groups based on their compositions, with an additional categorization for adjunct therapeutic drugs.

RESULTS

Of 32 confirmed STSS cases, all displayed sensitivity to ampicillin, β-lactam antibiotics, and vancomycin, but resistance to clindamycin, erythromycin, and tetracycline. From the literature, 23 studies with 50 cases were extracted, leading to a total of 82 patients for evaluation. The efficacy rates varied significantly among the four treatment groups. Notably, the standard penicillin-containing group exhibited the highest efficacy (86.4%), while the group with macrolides/unused antibiotics registered a 0% efficacy rate. The other two groups demonstrated efficacy rates of 32.1% and 42.3%.

CONCLUSION

For pediatric STSS, Streptococcus pyogenes shows notable sensitivity to ampicillin. Implementing timely β-lactam antibiotics, specifically penicillin, in conjunction with clindamycin and intravenous immunoglobulins enhances the treatment success rate.

The SEB1741 Aptamer Is an Efficient Tool for Blocking CD4+ T Cell Activation Induced by Staphylococcal Enterotoxin B

Staphylococcal enterotoxin B (SEB) is a protein produced by Staphylococcus aureus, which is toxic to humans. It is well known for its ability to stimulate the exacerbated activation of proinflammatory CD4+ T cells (Th1 profile), and in vitro studies have been conducted to understand its mechanism of action and its potential use as an immune therapy. However, the efficiency of the SEB1741 aptamer in blocking SEB has not been experimentally demonstrated.

METHODS

Enrichment CD4+ T cells were stimulated with SEB, and as a blocker, we used the SEB1741 aptamer, which was previously synthesised by an "in silico" analysis, showing high affinity and specificity to SEB. The efficiency of the SEB1741 aptamer in blocking CD4+ T cell activation was compared with that of an anti-SEB monoclonal antibody. Flow cytometry and Bio-Plex were used to evaluate the T-cell function.

RESULTS

In vitro, SEB induced the activation of CD4+ T cells and favoured a Th1 profile; however, the SEB1741 aptamer was highly efficient in decreasing the frequency of CD4+ T cells positive to ki-67 and CD69 cells, this means that proliferation and activation of CD4+ T cells was decreased. Moreover, the production of interleukin 2 (IL-2) and interferon-gamma (IFN-γ) was affected, suggesting that the Th1 profile is not present when the SEB1441 aptamer is used. Thus, the SEB1741 function was similar to that of anti-SEB.

CONCLUSIONS

The SEB1741 aptamer is a valuable tool for blocking CD4+ T cell activation and the subsequent release of proinflammatory cytokines by SEB stimulation.

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children: A 10-Year Single-Centre Experience from North India

OBJECTIVE

To describe the clinical and laboratory profile, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India.

METHODS

This retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011-December 2020) including children < 12 y with TSS (n = 63).

RESULTS

The median (interquartile range, IQR) age was 5 (2-9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12-17). The primary focus of infection was identified in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n = 11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fluid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n = 17). The duration of PICU and hopsital stay was 5 (4-10) and 7 (4-11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive-inotropic score.

CONCLUSION

TSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

An Overview of Clinical Manifestations of Dermatological Disorders in Intensive Care Units: What Should Intensivists Be Aware of?

Acute skin failure is rarely the primary diagnosis that necessitates admission to an intensive care unit. Dermatological manifestations in critically ill patients, on the other hand, are relatively common and can be used to make a key diagnosis of an adverse drug reaction or an underlying systemic illness, or they may be caused by factors related to a prolonged stay or invasive procedures. In intensive care units, their classification is based on the aetiopathogenesis of the cutaneous lesion and, in the meantime, distinguishes critical patients. When evaluating dermatological manifestations, several factors must be considered: onset, morphology, distribution, and associated symptoms and signs. This review depicts dermatological signs in critical patients in order to lay out better recognition.

Systemic immune activation profiles in streptococcal necrotizing soft tissue infections: A prospective multicenter study

OBJECTIVE

Early stages with streptococcal necrotizing soft tissue infections (NSTIs) are often difficult to discern from cellulitis. Increased insight into inflammatory responses in streptococcal disease may guide correct interventions and discovery of novel diagnostic targets.

METHODS

Plasma levels of 37 mediators, leucocytes and CRP from 102 patients with β-hemolytic streptococcal NSTI derived from a prospective Scandinavian multicentre study were compared to those of 23 cases of streptococcal cellulitis. Hierarchical cluster analyses were also performed.

RESULTS

Differences in mediator levels between NSTI and cellulitis cases were revealed, in particular for IL-1β, TNFα and CXCL8 (AUC >0.90). Across streptococcal NSTI etiologies, eight biomarkers separated cases with septic shock from those without, and four mediators predicted a severe outcome.

CONCLUSION

Several inflammatory mediators and wider profiles were identified as potential biomarkers of NSTI. Associations of biomarker levels to type of infection and outcomes may be utilized to improve patient care and outcomes.

High risk and low prevalence diseases: Adult bacterial meningitis

INTRODUCTION

Acute bacterial meningitis in adults is a rare but serious condition that carries a high rate of morbidity.

OBJECTIVE

This review highlights pearls and pitfalls of acute bacterial meningitis in adults, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Meningitis encompasses a broad spectrum of disease involving inflammation of the meninges and subarachnoid space. It classically presents with fever, nuchal rigidity, and altered mental status, but this triad is not present in all cases. Up to 95% of patients will have at least two of the following four cardinal symptoms: fever, nuchal rigidity, altered mental status, and headache. The most common bacterial etiologies are S. pneumoniae and N. meningitidis. Cerebrospinal fluid testing obtained by lumbar puncture remains the gold standard in diagnosis. Head computed tomography prior to lumbar puncture may not be necessary in most patients. Empiric treatment consists of vancomycin, ceftriaxone, and dexamethasone. Elevated intracranial pressure should be managed using established neurocritical care strategies.

CONCLUSION

A better understanding of the pearls and pitfalls of acute bacterial meningitis can assist emergency clinicians in pursuing its timely diagnosis and management.

Infections caused by Clostridium perfringens and Paeniclostridium sordellii after unsafe abortion

After the legalisation of abortion in the USA in 1973, the risk of infectious morbidity and mortality from this procedure notably decreased. With increasingly restrictive legislation targeting access to safe abortion services, reviewing infectious complications of unsafe pregnancy termination is crucial, particularly the diagnosis and management of life-threatening clostridial (and related anaerobic bacterial) infections that can complicate unsafe abortion. This Review deals with two especially devastating infections that are well-documented causes of septic abortion: the anaerobic, spore-forming pathogens Clostridium perfringens and Paeniclostridium sordellii. We seek to familiarise the reader with these bacteria, the clinical syndromes they can cause (with a focus on toxic shock syndrome), and provide a review of diagnosis and treatment options.

Pathophysiological Considerations in Periorbital Necrotizing Fasciitis: A Case Report

BACKGROUND

Periorbital necrotizing fasciitis (PNF) is a rare complication of bacterial infection, associated with irreversible inflammatory destruction of soft tissues like subcutaneous tissue and superficial fascia. PNF can cause visual loss, septic shock and death within hours to days. Since the infection progresses rapidly from a local disease to septic shock, prompt identification and decisive interventions are mandatory.

AIM

Considering pathophysiology, differential diagnosis, and treatment options, we report a case of PNF and its outcome.

METHODS

A 69 years old male with febrile periorbital swelling had been diagnosed with bilateral PNF, caused by dual infection with Streptococcus pyogenes (S. pyogenes) and Staphylococcus aureus (S. aureus) based on conjunctival swabs.

RESULTS

The superantigens produced by S. pyogenes have been identified as key to the rapid dissemination of infection and severity of systemic manifestations.

CONCLUSION

A combination of intravenous antibiotics and regular surgical debridements resulted in a beneficial outcome in our patient.

Post-abortion Complications: A Narrative Review for Emergency Clinicians

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Diagnostic MALDI-TOF MS can differentiate between high and low toxic Staphylococcus aureus bacteraemia isolates as a predictor of patient outcome

Staphylococcus aureus bacteraemia (SAB) is a major cause of blood-stream infection (BSI) in both healthcare and community settings. While the underlying comorbidities of a patient significantly contributes to their susceptibility to and outcome following SAB, recent studies show the importance of the level of cytolytic toxin production by the infecting bacterium. In this study we demonstrate that this cytotoxicity can be determined directly from the diagnostic MALDI-TOF mass spectrum generated in a routine diagnostic laboratory. With further development this information could be used to guide the management and improve the outcomes for SAB patients.

Case Report: Therapeutic Strategy With Delayed Debridement for Culture-Negative Invasive Group A Streptococcal Infections Diagnosed by Metagenomic Next-Generation Sequencing

Streptococcal toxic shock syndrome (STSS) caused by group A streptococcus is a rare condition that rapidly developed to multiple organ failure even death. Therefore, prompt diagnosis, initiate appropriate antibiotics and other supportive treatments are critical. Here we reported a case of STSS caused by group A streptococcus infection. A healthy 39-year-old man presented a sudden pain in the left lower extremity, followed by a high fever (40.0 °C) with dizziness, nausea, and shortness of breath. Twenty-four hours before the visit, the patient showed anuria. The patient was then admitted to the intensive care unit. Blood examination revealed elevated levels of inflammatory markers and creatinine. He suffered from septic shock, dysfunction of coagulation, acute kidney dysfunction, acute respiratory distress syndrome, and acute liver function injury. The diagnosis was obtained through clinical manifestation and metagenomic next-generation sequencing (mNGS) drawn from the pustule and deep soft tissue (lower limb) samples while all bacterial cultures came back negative. The pustule mNGS report detected a total of 132 unique group A streptococcus sequence reads, representing 96.3% of microbial reads while the soft tissue mNGS report identified a total of 142474 unique group A streptococcus sequence reads, representing 100% of microbial reads. The patient was treated with aggressive fluid resuscitation, antibiotics comprising piperacillin/tazobactam and clindamycin, respiratory support, following the delayed surgical debridement. Intravenous immunoglobulin was also used for 5 days. On the 14th day after admission, he was transferred to the general ward for follow-up treatment. Our case highlighted, for the first time, the key role of mNGS in the early diagnosis of culture-negative invasive group A streptococcal infection. The case also suggested that clindamycin combined with beta-lactam antibiotics and adjunction of intravenous immunoglobulin therapy with delayed debridement performed well in the management of unstable STSS patients.

Multisystem Inflammatory Syndrome in Children: Examining Emerging Data and Identifying Key Knowledge Gaps

ABSTRACT

Multisystem inflammatory syndrome in children (MIS-C) is a syndrome of abnormal immune response after severe acute respiratory syndrome coronavirus 2 infection that can result in organ dysfunction including severe cardiovascular compromise in children. Increased evidence supports a clinical and laboratory profile in MIS-C distinct from Kawasaki disease, with MIS-C typically occurring in older children and with more prominent gastrointestinal and neurologic symptoms, as well as increased inflammation, lymphopenia, and cardiac injury on laboratory testing. However, high-level evidence regarding best practices for treatment and long-term outcomes in MIS-C is limited.

Efficacy of Combination Therapy with the JAK Inhibitor Baricitinib in the Treatment of COVID-19

Coronavirus disease-19 (COVID-19), resulting from infection with SARS-CoV-2, spans a wide spectrum of illness. In severely ill patients, highly elevated serum levels of certain cytokines and considerable cytolytic T cell infiltrates in the lungs have been observed. These same patients may bear low to negligible viral burdens suggesting that an overactive immune response, often termed cytokine storm, contributes to the severity of COVID-19. We report the safety and efficacy of baricitinib combined with remdesivir and dexamethasone in a retrospective review of 45 hospitalized patients with COVID-19 pneumonia at a tertiary academic medical center. Patients received 7-day course of baricitinib, 5-day course of remdesivir, and 10-day course of dexamethasone. Clinical status and biomarkers were obtained daily. Outcomes assessed include mortality, duration of hospitalization, presence of shock, need for supplemental oxygen, need for non-invasive ventilation, need for mechanical ventilation, and development of thrombosis. Obesity and multiple medical comorbidities were associated with hospitalization in the setting of COVID-19. Treated patients demonstrated rapid declines of C-reactive protein (CRP), ferritin and D-dimer with gradual improvement in hemoglobin, platelet counts, and clinical status. Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment, and there were six deaths (13.3%). Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment. There were six deaths (13.3%) and these were associated with lower BMI. These findings support the utility of immunosuppression via JAK inhibition in moderate to severe COVID-19 pneumonia.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s42399-022-01121-4.

Severe and life-threatening COVID-19-related mucocutaneous eruptions: A systematic review

OBJECTIVES

Earlier diagnosis and the best management of virus-related, drug-related or mixed severe potentially life-threatening mucocutaneous reactions of COVID-19 patients are of great concern. These patients, especially hospitalised cases, are usually in a complicated situation (because of multi-organ failures), which makes their management more challenging. In such consultant cases, achieving by the definite beneficial management strategies that therapeutically address all concurrent comorbidities are really hard to reach or even frequently impossible.

METHODS

According to the lack of any relevant systematic review, we thoroughly searched the databases until 5 October 2020 and finally found 57 articles including 93 patients. It is needed to know clinical presentations of these severe skin eruptions, signs and symptoms of COVID in these patients, time of skin rash appearance, classifying drug-related or virus-related skin lesions, classifying the type of skin rash, patients' outcome and concurrent both COVID-19 therapy and skin rash treatment.

RESULT

Severe and potential life-threatening mucocutaneous dermatologic manifestations of COVID-19 usually may be divided into three major categories: virus-associated, drug-associated, and those with uncertainty about the exact origin. Angioedema, vascular lesions, toxic shock syndrome, erythroderma, DRESS, haemorrhagic bulla, AGEP, EM, SJS and TEN, generalised pustular figurate erythema were the main entities found as severe dermatologic reactions in all categories.

CONCLUSION

We can conclude vascular injuries may be the most common cause of severe dermatologic manifestations of COVID-19, which is concordant with many proposed hypercoagulation tendencies and systemic inflammatory response syndrome as one of the most important pathomechanisms of COVID-19 so the skin may show these features in various presentations and degrees.

Toxic shock syndrome complicated with symmetrical peripheral gangrene after liposuction and fat transfer: a case report and literature review

BACKGROUND

Liposuction is one of the most commonly performed aesthetic procedures. Toxic shock syndrome(TSS) is a rare, life-threatening complication. The incidence rate of TSS is very low in the plastic surgery field, especially after liposuction and fat transfer.

CASE PRESENTATION

A 23-year-old female patient was transferred to our emergency department from an aesthetic clinic with sepsis shock features after received liposuction and fat transfer. The patient underwent TSS, disseminated intravascular coagulation(DIC), multiple organ dysfunction syndrome (MODS), symmetrical peripheral gangrene (SPG), and necrotizing soft tissue infection of the buttocks in the next 10 days. Authors used a series of debridement and reconstructive surgery including vacuum sealing drainage (VSD) treatment, artificial dermis grafts,split-thickness skin grafts, amputation surgeries when her vital signs were stable. The patient experienced desquamation of the hand on the 26th day. The skin grafts survived and the function of both fingers and toes recovered. She was discharged 2 months after admission and was in good health.

CONCLUSION

TSS is extremely rare in the field of liposuction and autologous fat transfer. The mortality rate of TSS is very high. Early diagnosis and operative treatment, as well as correction of systemic abnormalities, are the important keys to save a patient's life.

Diagnosis and Management of Cellulitis and Abscess in the Emergency Department Setting: An Evidence-Based Review

BACKGROUND

Cellulitis and abscess are a common reason for presentation to the emergency department, although there are several nuances to the care of these patients.

OBJECTIVE

The purpose of this narrative review article was to provide a summary of the background, pathophysiology, diagnosis, and management of cellulitis and abscesses with a focus on emergency clinicians.

DISCUSSION

The most common bacteria causing cellulitis are Staphylococcus aureus, Streptococcus pyogenes, and other β-hemolytic streptococci, and methicillin-resistant S. aureus is most common in abscesses. The history and physical examination are helpful in differentiating cellulitis and abscess in many cases, and point-of-care ultrasound can be a useful tool in unclear cases. Treatment for cellulitis typically involves a penicillin or cephalosporin, and treatment of abscesses is incision and drainage. Loop drainage is preferred over the traditional incision and drainage technique, and adjunctive antibiotics can be considered. Most patients can be managed as outpatient.

CONCLUSIONS

It is essential for emergency physicians to be aware of the current evidence regarding the diagnosis and management of patients with cellulitis and abscess.

Management of Infectious Emergencies for the Inpatient Dermatologist

Purpose of Review

There are various dermatologic emergencies stemming from bacterial, viral, and fungal etiologies that can present in the inpatient setting. This review summarizes the pathogenesis and diagnosis of infections with cutaneous involvement and highlights new therapies.

Recent Findings

Clindamycin inhibits toxin formation and can be used as an adjunct therapy for the staphylococcal scalded syndrome. Isavuconazole therapy for mucormycosis infection is a less toxic alternative to amphotericin B.

Summary

Diagnosis of these infections is primarily guided by high clinical suspicion and early recognition can prevent dangerous sequelae. Treatment mainstays have been well-established, but there are adjunctive therapies that may potentially benefit the patient.

Efficacy of Combination Therapy With The JAK Inhibitor Baricitinib In The Treatment of COVID-19

BACKGROUND:

Coronavirus disease-19 (COVID-19), resulting from infection with SARS-CoV-2, spans a wide spectrum of illness. In severely ill patients, highly elevated serum levels of certain cytokines and considerable cytolytic T cell infiltrates in the lungs have been observed. These same patients may bear low to negligible viral burdens suggesting that an overactive immune response, often termed cytokine storm, contributes to the severity of COVID-19. We report the safety and efficacy of baricitinib combined with remdesivir and dexamethasone in 45 hospitalized patients with COVID-19 pneumonia at a tertiary academic medical center.

METHODS:

Retrospective review of 45 patients hospitalized with COVID-19 pneumonia. Patients received 7-day course of baricitinib, 5-day course of remdesivir and 10-day course of dexamethasone. Clinical status and biomarkers were obtained daily. Outcomes assessed include mortality, duration of hospitalization, presence of shock, need for supplemental oxygen, need for non-invasive ventilation, need for mechanical ventilation and development of thrombosis.

RESULTS:

Obesity and multiple medical comorbidities were associated with hospitalization in the setting of COVID-19. Treated patients demonstrated rapid declines of C-reactive protein (CRP), ferritin and D-dimer with gradual improvement in hemoglobin, platelet counts and clinical status. Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment and there were six deaths (13.3%).Only 2 of 45 (4.4%) treated patients required mechanical ventilation after initiating treatment. There were six deaths (13.3%) and these were associated with lower BMI.

CONCLUSIONS:

These findings support the utility of immunosuppression via JAK inhibition in moderate to severe COVID-19 pneumonia.

Streptococcal toxic shock syndrome in the setting of recent gynecologic surgery: A case report

Toxic shock syndrome (TSS) is an acute, toxin-mediated disease process which is commonly caused by Staphylococcus aureus or Streptococcus pyogenes. A high level of clinical suspicion is imperative, with prompt antibiotic therapy with a penicillinase-resistant penicillin (vancomycin in areas with increased methicillin-resistant Staphylococcus aureus) and clindamycin, given the high morbidity and mortality. Here, a case is reported of streptococcal-mediated TSS in a 37-year-old woman with a history of endometriosis, four days after a laparoscopic cystectomy; an intrauterine device (IUD) was left in situ at the time of uterine manipulation and not removed until hospital day 3 of the patient's readmission. Although no specific guidelines exist for removing IUDs, it is a foreign body and therefore it is recommended that early removal be considered regardless of the level of suspicion that it is the source of sepsis.

Treatment of Multisystem Inflammatory Syndrome in Children

BACKGROUND

Evidence is urgently needed to support treatment decisions for children with multisystem inflammatory syndrome (MIS-C) associated with severe acute respiratory syndrome coronavirus 2.

METHODS

We performed an international observational cohort study of clinical and outcome data regarding suspected MIS-C that had been uploaded by physicians onto a Web-based database. We used inverse-probability weighting and generalized linear models to evaluate intravenous immune globulin (IVIG) as a reference, as compared with IVIG plus glucocorticoids and glucocorticoids alone. There were two primary outcomes: the first was a composite of inotropic support or mechanical ventilation by day 2 or later or death; the second was a reduction in disease severity on an ordinal scale by day 2. Secondary outcomes included treatment escalation and the time until a reduction in organ failure and inflammation.

RESULTS

Data were available regarding the course of treatment for 614 children from 32 countries from June 2020 through February 2021; 490 met the World Health Organization criteria for MIS-C. Of the 614 children with suspected MIS-C, 246 received primary treatment with IVIG alone, 208 with IVIG plus glucocorticoids, and 99 with glucocorticoids alone; 22 children received other treatment combinations, including biologic agents, and 39 received no immunomodulatory therapy. Receipt of inotropic or ventilatory support or death occurred in 56 patients who received IVIG plus glucocorticoids (adjusted odds ratio for the comparison with IVIG alone, 0.77; 95% confidence interval [CI], 0.33 to 1.82) and in 17 patients who received glucocorticoids alone (adjusted odds ratio, 0.54; 95% CI, 0.22 to 1.33). The adjusted odds ratios for a reduction in disease severity were similar in the two groups, as compared with IVIG alone (0.90 for IVIG plus glucocorticoids and 0.93 for glucocorticoids alone). The time until a reduction in disease severity was similar in the three groups.

CONCLUSIONS

We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue. (Funded by the European Union's Horizon 2020 Program and others; BATS ISRCTN number, ISRCTN69546370.).

Toxic shock syndrome associated with menstrual cup use

Staphylococcal toxic shock syndrome is a rare but life-threatening condition. It occurs when Staphylococcus aureus bacteria colonizing the vagina of a healthy woman, produce toxic shock syndrome toxin 1 activating the immune system and leading to multiorgan failure. Menstrual cups also known as vaginal cups are usually used as alternatives to other intravaginal products for menstrual blood collection. In rare cases, they can also lead to toxic shock syndrome. We report a case of toxic shock syndrome associated with vaginal cup use in a healthy menstruating woman. The diagnosis was made based on the United States Centers for Disease Control and Prevention criteria of the syndrome and confirmed with a vaginal cultural growth of Staphylococcus aureus.

Multisystem inflammatory syndrome in children with COVID-19

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) is a dangerous pediatric complication of COVID-19.

OBJECTIVE

The purpose of this review article is to provide a summary of the diagnosis and management of MIS-C with a focus on management in the acute care setting.

DISCUSSION

MIS-C is an inflammatory syndrome which can affect nearly any organ system. The most common symptoms are fever and gastrointestinal symptoms, though neurologic and dermatologic findings are also well-described. The diagnosis includes a combination of clinical and laboratory testing. Patients with MIS-C will often have elevated inflammatory markers and may have an abnormal electrocardiogram or echocardiogram. Initial treatment involves resuscitation with careful assessment for cardiac versus vasodilatory shock using point-of-care ultrasound. Treatment should include intravenous immunoglobulin, anticoagulation, and consideration of corticosteroids. Interleukin-1 and/or interleukin-6 blockade may be considered for refractory cases. Aspirin is recommended if there is thrombocytosis or Kawasaki disease-like features on echocardiogram. Patients will generally require admission to an intensive care unit.

CONCLUSION

MIS-C is a condition associated with morbidity and mortality that is increasingly recognized as a potential complication in pediatric patients with COVID-19. It is important for emergency clinicians to know how to diagnose and treat this disorder.

A fatal toxic shock-like syndrome post COVID-19 infection in a child

Background

Children affected by Coronavirus disease 2019 (COVID-19) showed various manifestations. Some of them were severe cases presenting with multi-system inflammatory syndrome (MIS-C) causing multiple organ dysfunction.

Case presentation

We report the case of a 12-year-old girl with recent COVID-19 infection who presented with persistent fever, abdominal pain and other symptoms that meet the definition of MIS-C. She had lymphopenia and a high level of inflammatory markers. She was admitted to pediatric intensive care unit since she rapidly developed refractory catecholamine-resistant shock with multiple organ failure. Echocardiography showed a small pericardial effusion with a normal ejection fraction (Ejection Fraction = 60%) and no valvular or coronary lesions. The child showed no signs of improvement even after receiving intravenous immunoglobulin, fresh frozen plasma, high doses of Vasopressors and corticosteroid. His outcome was fatal.

Conclusion

Pediatric patients affected by the new COVID-19 related syndrome may show severe life-threatening conditions similar to Kawasaki disease shock syndrome. Hypotension in these patients results from heart failure and the decreased cardiac output. We report a new severe clinical feature of SARS-CoV-2 infection in children in whom hypotension was the result of refractory vasoplegia.

A case report of streptococcal toxic shock syndrome caused by Streptococcus mitis in a healthy adult

BACKGROUND

Streptococcal toxic shock syndrome (STSS) is an acute, multisystem and toxin-mediated disease that usually causes shock and multiple organ failure in the early stages of its clinical course. It is associated with a substantial increase in mortality rate. The disease has been associated with invasive group A Streptococcus and is rarely caused by Streptococcus mitis (S. mitis). In healthy adults, S. mitis is closely related to endocarditis but rarely related to STSS.

CASE PRESENTATION

We report a case of STSS caused by S. mitis in a healthy 45-year-old woman. She presented with fever 14 h after surgery and with hypotension 24 h later, and she subsequently suffered from septic shock, low albumin, dysfunction of coagulation, acute kidney dysfunction, respiratory alkalosis and metabolic acidosis, acute respiratory distress syndrome and cellulitis of the incision. The diagnosis was obtained through clinical manifestation and blood culture examination. The patient was treated with aggressive fluid resuscitation, adequate antibiotics for a total of 4 weeks, respiratory support, and surgical debridement and drainage of the incision. She was discharged after her vital signs returned to normal and the incision healed on day 40 after surgery.

CONCLUSIONS

The diagnosis of STSS is often delayed or missed, which leads to a high mortality rate. It is possible to cure patients if the disease can be identified early and treated with aggressive fluid resuscitation, adequate antibiotics and control of the source of infection. Clinicians should consider the disease in the differential diagnosis of septic shock to prevent death.

Phenotype and multi-omics comparison of Staphylococcus and Streptococcus uncovers pathogenic traits and predicts zoonotic potential

BACKGROUND

Staphylococcus and Streptococcus species can cause many different diseases, ranging from mild skin infections to life-threatening necrotizing fasciitis. Both genera consist of commensal species that colonize the skin and nose of humans and animals, and of which some can display a pathogenic phenotype.

RESULTS

We compared 235 Staphylococcus and 315 Streptococcus genomes based on their protein domain content. We show the relationships between protein persistence and essentiality by integrating essentiality predictions from two metabolic models and essentiality measurements from six large-scale transposon mutagenesis experiments. We identified clusters of strains within species based on proteins associated to similar biological processes. We built Random Forest classifiers that predicted the zoonotic potential. Furthermore, we identified shared attributes between of Staphylococcus aureus and Streptococcus pyogenes that allow them to cause necrotizing fasciitis.

CONCLUSIONS

Differences observed in clustering of strains based on functional groups of proteins correlate with phenotypes such as host tropism, capability to infect multiple hosts and drug resistance. Our method provides a solid basis towards large-scale prediction of phenotypes based on genomic information.

Infected abdominal aorta aneurysm secondary to streptococcal toxic shock syndrome due to Streptococcus pyogenes: a case report from Japan

Background

Infected aortic aneurysm secondary to streptococcal toxic shock syndrome caused by Streptococcus pyogenes is uncommon and associated with high mortality.

Case presentation

A 75‐year‐old man with metastatic lung cancer and an abdominal aortic aneurysm presented with high fever for 3 days. He was diagnosed with septic shock and was admitted to our hospital. The blood culture was positive for S. pyogenes, and streptococcal toxic shock syndrome was diagnosed. During treatment, enhanced computed tomography revealed an increase in the size of the abdominal aortic aneurysm, leading to the diagnosis of an infected aortic aneurysm. Replacement of the aneurysm with a synthetic graft was carried out successfully. The patient gradually recovered after the surgery.

Conclusion

We successfully managed an infected aortic aneurysm secondary to streptococcal toxic shock syndrome. Infected aortic aneurysms should be considered in patients with a medical history of aortic aneurysms and presenting with streptococcal toxic shock syndrome.

Dermatological Manifestations in the Intensive Care Unit: A Practical Approach

Dermatological problems are not usually related to intensive medicine because they are considered to have a low impact on the evolution of critical patients. Despite this, dermatological manifestations (DMs) are relatively frequent in critically ill patients. In rare cases, DMs will be the main diagnosis and will require intensive treatment due to acute skin failure. In contrast, DMs can be a reflection of underlying systemic diseases, and their identification may be key to their diagnosis. On other occasions, DMs are lesions that appear in the evolution of critical patients and are due to factors derived from the stay or intensive treatment. Lastly, DMs can accompany patients and must be taken into account in the comprehensive pathology management. Several factors must be considered when addressing DMs: on the one hand, the moment of appearance, morphology, location, and associated treatment and, on the other hand, aetiopathogenesis and classification of the cutaneous lesion. DMs can be classified into 4 groups: life-threatening DMs (uncommon but compromise the patient's life); DMs associated with systemic diseases where skin lesions accompany the pathology that requires admission to the intensive care unit (ICU); DMs secondary to the management of the critical patient that considers the cutaneous manifestations that appear in the evolution mainly of infectious or allergic origin; and DMs previously present in the patient and unrelated to the critical process. This review provides a characterization of DMs in ICU patients to establish a better identification and classification and to understand their interrelation with critical illnesses.

Thrombo-inflammation response to Tocilizumab in COVID-19

Background

Coronavirus disease‐19 (COVID‐19) spans a wide spectrum of illness. Severe cases of COVID‐19 can manifest inflammation in organs other than the lung, in tissues not known to support viral replication, and also in a hypercoagulable state. These observations have suggested that severe acute respiratory syndrome coronavirus 2 can provoke a hyperimmune response in some cases that could lead to secondary organ damage.

Methods

With evidence of elevated levels of interleukin‐6 (IL‐6) in patients with severe COVID‐19, we conducted a small pilot off‐label compassionate care study of the IL‐6 receptor inhibitor tocilizumab in patients with severe COVID‐19.

Results

A single infusion of tocilizumab in patients with severe COVID‐19 manifested rapid declines in C‐reactive protein and d‐dimer and gradual rises in lymphocyte and platelet counts.

Conclusions

These findings suggest both pathophysiological mechanisms and clinical benefit that might be seen with IL‐6 inhibition in severe COVID‐19.

Multisystem inflammatory syndrome in children: A systematic review

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C), also known as pediatric inflammatory multisystem syndrome, is a new dangerous childhood disease that is temporally associated with coronavirus disease 2019 (COVID-19). We aimed to describe the typical presentation and outcomes of children diagnosed with this hyperinflammatory condition.

METHODS

We conducted a systematic review to communicate the clinical signs and symptoms, laboratory findings, imaging results, and outcomes of individuals with MIS-C. We searched four medical databases to encompass studies characterizing MIS-C from January 1st, 2020 to July 25th, 2020. Two independent authors screened articles, extracted data, and assessed risk of bias. This review was registered with PROSPERO CRD42020191515.

FINDINGS

Our search yielded 39 observational studies (n = 662 patients). While 71·0% of children (n = 470) were admitted to the intensive care unit, only 11 deaths (1·7%) were reported. Average length of hospital stay was 7·9 ± 0·6 days. Fever (100%, n = 662), abdominal pain or diarrhea (73·7%, n = 488), and vomiting (68·3%, n = 452) were the most common clinical presentation. Serum inflammatory, coagulative, and cardiac markers were considerably abnormal. Mechanical ventilation and extracorporeal membrane oxygenation were necessary in 22·2% (n = 147) and 4·4% (n = 29) of patients, respectively. An abnormal echocardiograph was observed in 314 of 581 individuals (54·0%) with depressed ejection fraction (45·1%, n = 262 of 581) comprising the most common aberrancy.

INTERPRETATION

Multisystem inflammatory syndrome is a new pediatric disease associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is dangerous and potentially lethal. With prompt recognition and medical attention, most children will survive but the long-term outcomes from this condition are presently unknown.

FUNDING

Parker B. Francis and pilot grant from 2R25-HL126140. Funding agencies had no involvement in the study.

Device-Associated Menstrual Toxic Shock Syndrome

In the 1980s, menstrual toxic shock syndrome (mTSS) became a household topic, particularly among mothers and their daughters. The research performed at the time, and for the first time, exposed the American public as well as the biomedical community, in a major way, to understanding disease progression and investigation. Those studies led to the identification of the cause, Staphylococcus aureus and the pyrogenic toxin superantigen TSS toxin 1 (TSST-1), and many of the risk factors, for example, tampon use. Those studies in turn led to TSS warning labels on the outside and inside of tampon boxes and, as important, uniform standards worldwide of tampon absorbency labeling. This review addresses our understanding of the development and conclusions related to mTSS and risk factors. We leave the final message that even though mTSS is not commonly in the news today, cases continue to occur. Additionally, S. aureus strains cycle in human populations in roughly 10-year intervals, possibly dependent on immune status. TSST-1-producing S. aureus bacteria appear to be reemerging, suggesting that physician awareness of this emergence and mTSS history should be heightened.