Toxic shock syndrome in Infant/Neonate
Children are most susceptible to TSS between the ages of 6 months and 2 years. Before 6 months, the mother's antibodies are protective, and after age 2 years, the child begins producing antibody titers in higher amounts. TSS mortality rates are much lower in children than adults, at 5%-10% and 3%-5% for streptococcal versus staphylococcal types, respectively.
Note: An increase in invasive S pyogenes (invasive group A streptococcal [iGAS]) infections in children, including necrotizing fasciitis and streptococcal TSS, has been reported in Europe and the United States in 2022-2023.
TSS may result from surgical wounds, burns, or any other type of mucous membrane, skin, or soft tissue infection with S aureus. If the US Centers for Disease Control (CDC) criteria are strictly followed, TSS is extremely rare in infants (refer to Diagnostic Pearls section for CDC definition of staphylococcal TSS). Partial expression may be due to passive immunity conferred by maternal antibodies during the first 3-6 months of life, the increased tolerance of infantile T cells to superantigens, and early treatment leading to a blunted course. Names for these partial expressions of toxin-mediated disease include neonatal toxic shock syndrome-like exanthematous disease (NTED) and staphylococcal toxemia.
A48.3 – Toxic shock syndrome
18504008 – Toxic shock syndrome
Differential Diagnosis & Pitfalls
- Staphylococcal scalded skin syndrome
- Kawasaki disease – Fever lasting for more than 5 days with oral mucosal changes, conjunctival injection, and cervical lymphadenopathy.
- Multisystem inflammatory syndrome in children from COVID-19 infection
- Scarlet fever – 1-mm erythematous papules, always elevated WBC with left shift, eosinophilia in up to 20% of patients.
- Drug hypersensitivity syndrome (DRESS)
- Exanthematous drug eruption
- Toxic epidermal necrolysis (TEN)
- Stevens-Johnson syndrome (SJS)
- Contact dermatitis
- Pityriasis rubra pilaris
- Sezary syndrome (see cutaneous T-cell lymphoma)
- Necrotizing fasciitis – Rapidly progressing necrosis of fascia and subcutaneous fat.
- Meningococcemia – Rapid decompensation, characteristic petechial eruption caused by Neisseria meningitidis.
- Rocky Mountain spotted fever – Characteristic retiform purpura; check for serologies.