Streptococcal Toxic Shock Syndrome Following Influenza A Infection in Two Children.

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To the Editors: Clinicians in several European countries and the United States have reported an increase in cases of invasive group A streptococcus (GAS) infections in children <10 years old during the fall and winter of 2022.1 This increase is thought to possibly be associated with increased circulation of respiratory viruses such as influenza.1,2 Herein, we report 2 children with streptococcal toxic shock syndrome (STSS) following influenza A infection. CASE 1 A previously healthy 9-year-old girl presented with fever, rash, vomiting and diarrhea on December 6, 2022. The patient had a documented influenza infection one week before admission. The respiratory viral panel was positive for influenza A (H1N1). Physical examination revealed fever (up to 39.5 °C), hypotension (75/40 mm Hg), circumoral pallor, strawberry tongue, and generalized erythematous rash that blanches with pressure (Fig. 1A). Laboratory tests showed leukocytosis (21,520/mm3), thrombocytopenia (88,000/mm3), elevated acute phase reactants (C-reactive protein 180 mg/L, procalcitonin 10 ng/mL), renal insufficiency (serum creatinine level 1.8 mg/dL) and coagulopathy (fibrinogen 318 mg/dL, prothrombin time 17 seconds, activated partial thromboplastin time 40 seconds). After blood and throat cultures were obtained, treatment with empirical intravenous ampicillin/sulbactam and clindamycin was started. Due to persistent hypotension, resuscitation was initiated with intravenous fluids and inotropes, and she was transferred to pediatric intensive care unit (PICU). On day 2, GAS was isolated from blood and throat cultures. The patient met the diagnostic criteria of confirmed STSS with hypotension, rash, renal impairment, coagulopathy, and isolation of GAS from a sterile site.3 The patient was discharged 10 days after admission. On a follow-up examination 14 days after admission, desquamation of the palms and soles was noted.Figure 1.: Clinical photographs of patients with streptococcal toxic shock syndrome. Circumoral pallor, strawberry tongue and generalized erythematous rash (A) and a petechial rash and desquamation on the patient’s face (B).CASE 2 A previously healthy 10-year-old boy presented to our hospital with fever, chills, rash, myalgia and diarrhea on December 19, 2022. The patient had upper respiratory symptoms for 5 days. On examination, he had a body temperature of 38 °C, heart rate of 126/min, blood pressure of 80/40 mm Hg, pharyngeal erythema, an erythematous rash on his trunk and extremities and a petechial rash on his face (Fig. 1B). Laboratory tests showed elevated levels of acute phase reactants, serum creatinine, D-dimer and prolonged prothrombin time and international normalized ratio. Empirical intravenous therapy with ampicillin/sulbactam and clindamycin was initiated after obtaining blood and throat cultures. He required both intravenous fluids and inotropes for the treatment of severe hypotension and was transferred to PICU. The respiratory viral panel was positive for influenza A. On day 2, GAS was isolated from the throat culture. The patient was diagnosed to have probable STSS with the presence of hypotension, rash, renal impairment, coagulopathy and isolation of GAS from a nonsterile site.3 On day 3, the patient’s clinical condition improved and he was transferred from PICU to the pediatric ward. On day 4, he demonstrated desquamation of the face (Fig. 1B), trunk and extremities. He was discharged 9 days after admission. Our cases highlight that clinicians should consider STSS in children presenting with fever, rash, hypotension, and multiorgan involvement, especially in those with concurrent or preceding influenza infection.