Fatal Group a Streptococcal Toxic Shock-Like Syndrome in a Child With Varicella: Report of the First Well Documented Case With Detection of the Genetic Sequences That Code for Exotoxins Spe a and B, in São Paulo, Brazil

Background Necrotising fasciitis is a rapidly progressing soft-tissue infection with a low incidence that carries a relevant risk of morbidity and mortality. Although necrotising fasciitis is often fatal in adults, its case fatality rate seems to be lower in children. A highly variable clinical presentation makes the diagnosis challenging, which often results in misdiagnosis and time-delay to therapy. Methods We conducted a protocol-based systematic review to identify specific features of necrotising fasciitis in children aged one month to 17 years. We searched ’PubMed’, ’Web of Science’ and ’SCOPUS’ for relevant literature. Primary outcomes were incidence and case fatality rates in population-based studies, and skin symptoms on presentation. We also assessed signs of systemic illness, causative organisms, predisposing factors, and reconstructive procedures as secondary outcomes. Results We included five studies reporting incidence and case fatality rates, two case-control studies, and 298 cases from 195 reports. Incidence rates varied between 0.022 and 0.843 per 100,000 children per year with a case-fatality rate ranging from 0% to 14.3%. The most frequent skin symptoms were erythema (58.7%; 175/298) and swelling (48%; 143/298), whereas all other symptoms occurred in less than 50% of cases. The majority of cases had fever (76.7%; 188/245), but other signs of systemic illness were present in less than half of the cohort. Group-A streptococci accounted for 44.8% (132/298) followed by Gram-negative rods in 29.8% (88/295), while polymicrobial infections occurred in 17.3% (51/295). Extremities were affected in 45.6% (136/298), of which 73.5% (100/136) occurred in the lower extremities. Skin grafts were necessary in 51.6% (84/162) of the pooled cases, while flaps were seldom used (10.5%; 17/162). The vast majority of included reports originate from developed countries. Conclusions Clinical suspicion remains the key to diagnose necrotising fasciitis. A combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotising fasciitis. Incidence and case-fatality rates in children are much smaller than in adults, although there seems to be a relevant risk of morbidity indicated by the high percentage of skin grafts. Systematic multi-institutional research efforts are necessary to improve early diagnosis on necrotising fasciits. Electronic supplementary material The online version of this article (10.1186/s12879-019-3941-3) contains supplementary material, which is available to authorized users.

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A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018

Schröder¹,

Gerin

Firth

et al. 2019

BMC Infect Dis

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Invasive Group A Streptococcal Infections, Israel

Moses

Goldberg²,

Korenman³

et al. 2002

Emerg. Infect. Dis.

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We conducted a prospective, nationwide, population-based study of invasive group A streptococcal infections in Israel. We identified 409 patients (median age 27 years; range <1-92), for an annual incidence of 3.7/100,000 (11/100,000 in Jerusalem). The mortality rate was 5%. Bacteremia occurred in 125 cases (31%). The most common illnesses were soft-tissue infection (63%) and primary bacteremia (14%). Thirty percent of patients had no identifiable risk factors for infection. Eighty-seven percent of pharyngeal carriers had the same serotype as the index patient. M types included M3 (25%), M28 (10%), and M-nontypable (33%). A marked paucity of M1 serotype (1.2%) was detected. The results highlighted concentrated pockets of invasive disease in the Jewish orthodox community (annual incidence 16/100,000).

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Fatal Group a Streptococcal Toxic Shock-Like Syndrome in a Child With Varicella: Report of the First Well Documented Case With Detection of the Genetic Sequences That Code for Exotoxins Spe a and B, in São Paulo, Brazil

Cited by 2 publications

References 18 publications

A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018

A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018

Invasive Group A Streptococcal Infections, Israel

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