A 2-year-old boy with circulatory failure owing to streptococcal toxic shock syndrome: case report.
Werner KeenswijkVande Walle JohanPublished in: Paediatrics and international child health (2017)
A 2-year-old boy presented with severe hypotension and acute kidney injury after a prodrome of non-bloody diarrhoea and fever in the preceding 3 days. He had a mild Ebstein cardiac anomaly but otherwise a normal past history and growth. On examination, he looked ill, his temperature was 37.5 °C, circulation was poor, and there were several purpuric lesions on the face, hands and scrotum. Haemoglobin was 7.8 g/dL (11-14), total white cell count 27 × 109/L, platelets 62 × 109/L, blood urea nitrogen 20.7 mmol/L (4.2-17.1), serum creatinine 95.4 μmol/L (21.2-36.2), CRP 154 mg/L (<5), AST 296 U/L (11-50), ALT 909 U/L (7-40) and C3 component of complement 0.8 g/L (0.9-1.8). Activated partial thromboplastin time (APTT) and prothrombin time (PT) were prolonged and fibrinogen level was 1.0 g/L (2-4). He received immediate fluid resuscitation (IV 0.9% saline solution, 2 × 10 ml/kg boluses, followed by glucose 5/0.45% sodium chloride solution, 2 × 10 ml/kg) and antibiotics (ciprofloxacin and amikacin) but circulation continued to deteriorate with development of decreased consciousness. He was placed on mechanical ventilation and vasopressor agents were added. Despite improved circulation over the next 2 days, he developed oliguria, progressive fluid overload, generalised oedema and a right-sided pleural effusion. Dialysis was commenced on day 3 of admission. Differential diagnosis included sepsis, atypical haemolytic uraemic syndrome and lupus nephritis. Blood and urine cultures remained negative but an anti-streptolysin O titre of 1318 (<200) IU/mL led to the diagnosis of streptococcal toxic shock syndrome which is rare in early childhood and associated with high mortality. Haemodialysis was commenced and continued for 10 days with successful treatment of fluid overload and subsequent extubation. Renal function was completely restored over the following 6 weeks and he was discharged in good clinical condition about 2 months after intial admission. The clinical course and outcome are discussed, and the importance of timely initiation of dialysis when there is fluid overload is emphasised.
Keyphrases
- case report
- mechanical ventilation
- acute kidney injury
- intensive care unit
- chronic kidney disease
- end stage renal disease
- cardiac surgery
- emergency department
- acute respiratory distress syndrome
- cardiac arrest
- pseudomonas aeruginosa
- type diabetes
- single cell
- septic shock
- left ventricular
- heart failure
- respiratory failure
- cystic fibrosis
- cell therapy
- cardiovascular events
- multiple sclerosis
- early onset
- metabolic syndrome
- cardiovascular disease
- uric acid
- solid state
- glycemic control
- atrial fibrillation