Skin care for toxic shock syndrome: case report / Cuidados com a pele na síndrome do choque tóxico: relato de caso / Cuidado de la piel en el síndrome de shock tóxico: reporte de caso

Objetivo: A síndrome do choque tóxico (SCT) é uma condição multissistêmica grave, causada por Staphylococcus aureus ou Streptococcus pyogenes,e o manejo inicial e contínuo das lesões de pele é essencial para o controle da infecção. Este relato teve o objetivo de descrever os cuidados com a pele nessa síndrome. Relato do caso: Paciente do sexo masculino com abscesso no quadril que evoluiu com febre e hipotensão e consequente transferência para a Unidade de Terapia Intensiva (UTI). Foi diagnosticado com choque séptico de provável foco no quadril, imediatamente abordado cirurgicamente para tratamento local da infecção. Apresentou insuficiência renal, além de disfunção multissistêmica (hepática e cardíaca), instabilidade hemodinâmnica e lesões disseminadas de pele. Com o isolamento do Staphylococcus aureus, iniciou-se clindamicina e o diagnóstico foi de SCT, uma vez que apresentou lesões epidermolíticas desde o início do quadro. Foram iniciadas medidas de recuperação cutânea com a sulfadiazina de prata e, posteriormente, com hidrofibra com prata com restauração do epitélio em 8 dias. Após 10 dias da pele restaurada, o paciente recebeu alta da UTI para enfermaria com manutenção do tratamento proposto. Conclusão: Neste caso, o uso da hidrofibra obteve uma performancesatisfatória, contudo ainda há necessidade de estudos robustos que comprovem tal eficácia. (AU)

Objective: Toxic shock syndrome (TSS) is a severe multisystemic condition caused by Staphylococcus aureus or Streptococcus pyogenes, and initial management of skin lesions is essential for infection control. This article aimed to describe skin care for TSS. Case report: We report a man with a hip abscess who developed fever and hypotension and was subsequently transferred to an intensive care unit (ICU). He was diagnosed with septic shock, probably of hip origin, and was immediately treated surgically for local infection control. He presented with renal failure besides multiple organ dysfunction (hepatic and cardiac), hemodynamic instability, and disseminated skin lesions. With the isolation of Staphylococcus aureus, clindamycin was initiated, and the diagnosis was TSS due to epidermolytic lesions since the onset of the condition. Cutaneous recovery measures were initiated with silver sulfadiazine, followed by silver hydrofiber with skin recovery in 8 days. After 10 days of skin recovery, the patient was discharged from the ICU to the ward with maintenance of the proposed treatment. Conclusion: In this case, the use of hydrofiber showed satisfactory performance; however, robust studies are needed to confirm such efficacy. (AU)

Objetivo: El síndrome de shock tóxico (SST) es una afección multisistémica grave causada por Staphylococcus aureuso Streptococcus pyogenes, y el tratamiento inicial y continuo de las lesiones cutáneas es esencial para controlar la infección. Este informe tuvo como objetivo describir los cuidado de la piel en este síndrome. Reporte del caso:Paciente masculino con absceso en la cadera que desarrolló fiebre e hipotensión y fue tranferido a la Unidad de Cuidados Intensivos (UCI). Se diagnosticó shock séptico, probablemente focalizado en la cadera, por lo que fue inmediatamente abordado quirúrgicamente para tratamiento local de la infección. Presentó insuficiencia renal además de disfunción multisistémica (hepática y cardiaca), inestabilidad hemodinámica y lesiones cutáneas diseminadas. Con el aislamiento de Staphylococcus aureus, se inició clindamicina y el diagnóstico fue SST, ya que presentaba lesiones epidermolíticas desde el inicio del cuadro. Se iniciaron medidas de recuperación cutánea con sulfadiazina de plata y, posteriormente, se optó por hidrofibra con plata, con restauración del epitelio en 8 días. Después de 10 días de piel restaurada, el paciente fue dado de alta de la UCI a planta con mantenimiento del tratamiento propuesto. Conclusión: Alcen este caso, el uso de hidrofibra obtuvo un desempeño satisfactorio, sin embargo, aún se necesitan estudios robustos para probar tal eficacia. (AU)

Optimization and evaluation of a multiplex PCR assay for detection of Staphylococcus aureus and its major virulence genes for assessing food safety.

Staphylococcus aureus is a natural commensal microflora of humans which causes opportunistic infections due to its large arsenal of exotoxins, invasion, immune evasion, and antibiotic resistance mechanisms. The primary goal of this study is to develop a multiplex PCR (mPCR) assay for simultaneous detection of Staphylococcus aureus (nuc) and its virulence genes coding for prominent exotoxins namely alpha hemolysin (hla), enterotoxins A (sea), enterotoxin B (seb), toxic shock syndrome toxin (tsst-1), and the gene coding for methicillin resistance (mecA). A competitive internal amplification control (IAC) was included in the assay to exclude the false negative outcomes. Highly specific primer pairs were designed for the target genes using in silico resources. At the outset, monoplex PCRs were standardized using reference S. aureus strains. Primer specificity to the target genes was authenticated through restriction digestion analysis of amplified PCR products. Multiplex PCR was optimized in increments of one gene starting with nuc and IAC amplified simultaneously using one pair of primers (nuc) in a competitive manner. The mPCR assay was found to be highly sensitive with a detection limit of ~10 CFUs per reaction for pure cultures. Multiplex PCR assay was further evaluated on the retail and processed food samples to test the prevalence of S. aureus and study their exotoxin profiles. Of the 57 samples examined, 13 samples (22.80%) were found to be contaminated with S. aureus whose DNA was extracted after a 6-h enrichment period. Among these, a high percentage of hemolytic and enterotoxin A positive strains were encountered. The mPCR assay developed in this study would be a useful tool for rapid and reliable monitoring of S. aureus for food quality testing and from clinical infections.

High Prevalence of Panton-valentine Leukocidin-encoding Genes in Methicillin-resistant Staphylococcus aureus Isolated from Inpatients with Invasive Infections at a University Hospital in Southern Brazil.

BACKGROUND: Staphylococcus aureus is a major cause of a wide diversity of infections in humans, and the expression of Panton-Valentine Leukocidin (PVL) has been associated with severe clinical syndromes. OBJECTIVES: The present study aimed to investigate the prevalence of PVL-encoding genes in S. aureus isolated from clinical samples of inpatients with invasive infections in a teaching hospital in Southern Brazil. Furthermore, phenotypic and genotypic characteristics of bacterial isolates were analyzed. METHODS: A total of 98 S. aureus isolates recovered from different body sites were characterized according to their antimicrobial susceptibility profile, methicillin-resistance and SCCmec typing, genetic relatedness and occurrence of virulence-encoding genes, such as icaA, lukS-PV/lukF-PV, and tst. RESULTS: Sixty-eight (69.4%) isolates were classified as methicillin-resistant, and among them, four (5.9%) did not harbor the mecA gene. The mecA-harboring methicillin-resistant S. aureus (MRSA) isolates were grouped into SCCmec types I (6.3%), II (64.1%), III (6.3%), IV (15.6%), V (4.7%), and VI (1.6%). One isolate (1.6%) was classified as non-typeable (NT). Seventy isolates (71.4%) were classified as multidrug-resistant. The overall prevalence of virulence-encoding genes was as follows: icaA, 99.0%; tst, 27.5%; and lukS-PV/lukF-PV, 50.0%. The presence of tst gene was significantly higher (p < 0.001) in methicillin-susceptible S. aureus (MSSA) compared to MRSA isolates. CONCLUSION: The present study reports a high prevalence of multidrug-resistant S. aureus harboring lukS-PV/lukF-PV and tst genes in invasive infections. The continuous monitoring of the antimicrobial susceptibility profile and virulence of S. aureus is an important measure for the control of infections caused by this bacterium.

Síndrome de choque tóxico por Streptococcus pyogenes en un hospital de la Ciudad de México / Toxic shock syndrome caused by Streptococcus in a hospital from the Mexico City / Síndrome de choque tóxico por Streptococcus pyogenes em um hospital da Cidade do México

Resumen: El síndrome de choque tóxico por Streptococcus se describió por primera vez en 1978 por Todd y su equipo. Éste incluye datos de hipotensión, disoxia celular, aislamiento de Streptococcus pyogenes, así como la inclusión de dos o más de los siguientes criterios: síndrome de dificultad respiratoria aguda, insuficiencia renal, anormalidad hepática, coagulopatía y erupción cutánea con descamación. Es una enfermedad relativamente rara entre niños y adultos; representa una alta mortalidad, la cual oscila de 23 al 70%. En más de la mitad de los casos, se desconoce la causa de entrada de este patógeno al torrente sanguíneo, aunque los pacientes con alcoholismo, en los extremos de la vida, con comorbilidades (como enfermedad renal crónica, insuficiencia hepática y leucemias) y que hayan sido sometidos a esplenectomía son más susceptibles al contagio y a infecciones severas. En los pacientes que desarrollan infecciones de tejidos blandos profundos, como fascitis necrosante o infección intrauterina, el dolor severo es el síntoma inicial más frecuente.

Abstract: Streptococcal toxic shock syndrome was first described by Todd and collaborators in 1978, this syndrome includes hypotension, traces of cellular dysoxia, isolation Streptococcus pyogenes; as well as two or more of the following criteria: acute respiratory distress syndrome, renal failure, liver abnormality, coagulopathy, skin rash with necrosis flaking of soft tissues. It is a relatively rare disease among children and adults, representing a high mortality ranging from 23 to 70%. In more than half of the cases the cause of entry of this pathogen into the bloodstream is unknown, although patients with alcoholism, on the edge of death, with splenectomy, with comorbidities (chronic kidney disease, liver failure, leukemia) are more susceptible to infection, to acquire severe infections and shock. Cutaneous infections usually are followed by minor skin irritations (insect bites), 20% of the cases experience a flu-like syndrome (fever, chills, myalgia and diarrhea). In patients who develop deep soft tissue infections such as necrotizing fasciitis or intrauterine infection, the severe pain is the most common initial symptom of streptococcal TSS.

Resumo: A síndrome do choque tóxico estreptocócico foi descrita pela primeira vez por Todd et al em 1978, incluindo dados sobre hipotensão, disxia celular, isolamento de Streptococcus pyogenes, bem como 2 ou mais dos seguintes critérios: síndrome do desconforto respiratório agudo, insuficiência renal, anormalidade hepática, coagulopatia, erupção cutânea com descamação. É uma doença relativamente rara em crianças e adultos, representa uma alta mortalidade que varia de 23 a 70%. Em mais da metade dos casos, a causa desse patógeno na corrente sanguínea é desconhecida, embora pacientes com alcoolismo, extremos da vida, com esplenectomia e comorbidades (como doença renal crônica, insuficiência hepática, leucemia) sejam mais suscetíveis à infecção e infecções graves. Em pacientes que desenvolvem infecções profundas dos tecidos moles, como fasceíte necrozante ou infecção intra-uterina, a dor intensa é o sintoma inicial mais frequente.

Toxic shock syndrome caused by Streptococcus dysgalactiae subsp. equisimilis in a Mexican preschool patient.

Background: Severe infections due to Streptococcus dysgalactiae subsp. equisimilis (SDSE) have been identified in adults and may cause toxic shock syndrome, although with a low frequency. Case report: A preschool-age female patient, who started with an upper respiratory tract infection developing a gradual deterioration in the following three days, is described. She was admitted to the hospital in severe conditions, with tachypnea, tachycardia (200/min), hypotension (blood pressure 68/40 mmHg), capillary refill of 7 s, and erythematous maculopapular rash in thorax, abdomen and lower extremities. She received intensive management with an inadequate response. Furthermore, she developed multiple organ failure and died 8 h after admission. The blood culture was positive for S. dysgalactiae subsp. equisimilis. Conclusions: SDSE is a rare pathogen in children. In Mexico, cases of SDSE have not been reported probably due to an inaccurate identification. Mexican pediatricians should be alert to this situation..

Introducción: En adultos, se han identificado infecciones graves por Streptococcus dysgalactiae subsp. equisimilis (SDSE), que pueden causar el síndrome de choque tóxico causado por SDSE, aunque es de baja frecuencia. Caso clínico: Paciente de sexo femenino en edad preescolar. Comenzó con una infección del tracto respiratorio superior, y desarrolló un deterioro gradual en los siguientes tres días. Ingresó en el hospital en condiciones graves, con taquipnea, taquicardia (200/min), hipotensión (tensión arterial, TA 68/40 mmHg), llenado capilar de 7 s y erupción maculopapular eritematosa en el tórax, abdomen y extremidades inferiores. Recibió manejo intensivo, sin una buena respuesta. Posteriormente, desarrolló datos de falla orgánica múltiple y murió 8 h después de su ingreso. El hemocultivo fue positivo para S. dysgalactiae subsp. equisimilis. Conclusiones: El SDSE es un patógeno raro en los niños. En México, no se han reportado casos de SDSE probablemente debido a una identificación errónea. Los pediatras mexicanos deben estar atentos a esta situación.

Kawasaki disease shock syndrome: Unique and severe subtype of Kawasaki disease.

BACKGROUND: Kawasaki disease shock syndrome (KDSS) is an uncommon presentation of Kawasaki disease (KD). KDSS has been associated with more severe markers of inflammation, coronary abnormalities and i.v. immunoglobulin (IVIG) resistance. METHODS: A retrospective, descriptive study of children with KDSS in two hospitals was performed. Relevant articles about KD and shock were collected, and demographic data, clinical presentation, laboratory variables, echocardiogram findings, treatment and special features were analyzed when available. Twelve patients diagnosed with KDSS were retrospectively reviewed from two centers in Mexico, along with 91 additional cases from the literature. RESULTS: Seventy-two patients presented with complete KD (69.9%), and 30.1% (31/103) had unusual KD manifestations. The most frequent diagnosis at the time of admission was toxic shock syndrome (TSS; n = 20). Sixteen of the 20 had coronary artery abnormalities. Overall, abnormalities in the coronary arteries were documented in 65% of the patients. The mortality rate was 6.8%. CONCLUSION: The presence of coronary aneurysms was significantly and positively correlated with male gender, IVIG resistance, inotrope treatment, cardiac failure, abdominal pain and neurological symptoms. IVIG-resistant patients had higher neutrophil : lymphocyte ratio. Abdominal symptoms, hypoalbuminemia and elevated C-reactive protein were present in almost all of the patients. Multisystem involvement with atypical presentation in KDSS is frequent. An important differential diagnosis is TSS. Mechanical ventilation, gastrointestinal and neurological symptoms were associated with IVIG resistance and the presence of coronary aneurysms. The first line of treatment includes IVIG and pulse corticosteroids; in severe cases, infliximab, anakinra, cyclosporine or plasmapheresis are alternative treatment options.

Fasciitis and Streptococcal Toxic-shock Syndrome: The Importance of Early Diagnosis and Surgical Management.

INTRODUCTION: Fasciitis of the limb and toxic-shock syndrome due to Streptococcus Pyogenes infection is considered a surgical emergency. This condition may occur in previously healthy patients. It is a life-threatening condition with high morbidity rates when treatment is delayed due to poor diagnosis and non-surgical intervention. CASE REPORT: 17-year-old male patient sustained a minor ankle trauma while skating. Initials findings were a 1cm wound in relation with his left lateral malleolus and moderate swelling. About 6 h later, the patient was admitted at the emergency room with disproportionate limb pain, increased swelling, persistent fever, paleness, tachycardia, and hypotension. The patient was intubated due to his unstable hemodynamic condition and underwent fasciotomy of the limb. A vacuum-assisted closure device was used. After the first surgical procedure, patient's condition radically improved. He was extubated with good clinical prognosis. He underwent several surgical procedures in a 3-weeks lapse until the wound finally healed. CONCLUSION: Streptococcal toxic-shock syndrome and limb fasciitis have no specific early signs or symptoms. It seems that clinical dissociation (disproportionate pain together with a minor wound) should become an alarm sign to trauma surgeons. It is important to contemplate this serious condition as differential diagnosis in every patient undergoing trauma with torpid evolution. Aggressive surgical management is the gold standard treatment and should not be delayed.

Occurrence of toxin genes in Staphylococcus pseudintermedius from diseased dogs and other domestic and wild species.

INTRODUCTION: Staphylococcus pseudintermedius is coagulase-positive species of the Staphylococcus intermedius group. It is an opportunistic pathogen that can cause infection in various parts of the body and has a zoonotic potential. Although studies on the pathogenicity and epidemiology of S. pseudintermedius are limited, it is known that this bacterium has several virulence factors, including toxins. These toxins can be classified into three main groups: pyrogenic toxins with superantigenic properties such as toxic shock syndrome toxin and staphylococcal enterotoxins, exfoliative toxins, and cytotoxins  such as hemolysins and leukocidins. METHODOLOGY: In this study, the occurrence of eight toxin genes (sea, sec, tst, SIET, EXI, LuK F-I, Luk S-I, and hlg Æ´) was examined by PCR in 58 isolates of S. pseudintermedius from four domestic animal species. RESULTS: All S. pseudintermedius isolates had at least one of the eight toxin genes. The predominant toxin genes were Luk S-I (95%), Luk F-I (91%), and EXI (91%), and the least prevalent gene was hlg Æ´ (5%). Significant association (p = 0.0175) was found between the occurrence patterns of genes hlg Æ´ and Luk F-I. CONCLUSIONS: The frequent occurrence of these genes in S. pseudintermedius obtained from diseased animals indicates that these toxins may play an important role in the pathogenesis of infection among domestic animals.

A 2-year-old boy with circulatory failure owing to streptococcal toxic shock syndrome: case report.

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.

Genomic Comparison among Lethal Invasive Strains of Streptococcus pyogenes Serotype M1.

Streptococcus pyogenes, also known as group A Streptococcus (GAS), is a human pathogen that causes diverse human diseases including streptococcal toxic shock syndrome (STSS). A GAS outbreak occurred in Brasilia, Brazil, during the second half of the year 2011, causing 26 deaths. Whole genome sequencing was performed using Illumina platform. The sequences were assembled and genes were predicted for comparative analysis with emm type 1 strains: MGAS5005 and M1 GAS. Genomics comparison revealed one of the invasive strains that differ from others isolates and from emm 1 reference genomes. Also, the new invasive strain showed differences in the content of virulence factors compared to other isolated in the same outbreak. The evolution of contemporary GAS strains is strongly associated with horizontal gene transfer. This is the first genomic study of a Streptococcal emm 1 outbreak in Brazil, and revealed the rapid bacterial evolution leading to new clones. The emergence of new invasive strains can be a consequence of the injudicious use of antibiotics in Brazil during the past decades.

Biofilm and toxin profile: A phenotypic and genotypic characterization of coagulase-negative staphylococci isolated from human bloodstream infections.

Coagulase-negative staphylococci (CNS) represent one of the most prevalent microorganisms in nosocomial infections worldwide, nevertheless little is known about their pathogenicity features. Thus, our aim was to characterize virulence aspects of CNS isolated from patients with bloodstream infections assisted in hospitals of Belo Horizonte, MG, Brazil. Strains were identified using bioMérieuxVitek® and for biofilm production evaluation, Congo Red Agar (CRA) and polystyrene plates were used. PCR was applied to detect icaA, icaB, icaC, atlE, sea, sec, sed, tsst-1 and agr. For statistical analyses were used hierarchical cluster, chi-square test and correspondence. 59 strains were analyzed, being S. haemolyticus the most prevalent. On CRA, 96.5% were biofilm producer, whereas on polystyrene plate, 100% showed adhesion at different times evaluated. Regarding genotypic analyses, 15.2%, 38.9%, 8.4%, 49.1%, 76.2%, 23.7%, 1.6%, 30.5% and 38.9% were positive for icaA, icaB, icaC, atlE, sea, sec, sed, tsst-1 and agr, respectively. Six clusters were formed and frequency distributions of agr, atlE, icaA, icaB, sea, sec, tsst-1 differed (P < 0.001). In conclusion, all strains were biofilm producer, with high prevalence of atlE, and had potential of toxin production, with high prevalence of sea. According to the group-analyses, icaB showed relationship with the strong adherence in samples.

Estudio multicéntrico de infecciones invasivas por Streptococcus pyogenes en niños de Argentina / Multicenter study on invasive Streptococcus pyogenes infections in children in Argentina

Introducción. Las infecciones invasivas por Streptococcus pyogenes (IISP) presentan elevada morbimortalidad aún en la actualidad; no obstante, a nivel regional, existen escasas publicaciones en pediatría. Objetivo. Describir la prevalencia, los factores predisponentes y las características clínicas de niños internados por IISP, analizar los factores de riesgo asociados a bacteriemia y letalidad. Material y métodos. Estudio retrospectivo, descriptivo de IISP en niños ≤ 18 años, internados en Pediatría de 20 centros asistenciales del país, entre 2010 y 2012. Variables evaluadas: edad, sexo, focos clínicos iniciales y tardíos, patología crónica previa, factores predisponentes, tratamiento y evolución. Resultados. Se analizaron 143 pacientes. Incidencia de 4,97 casos/10 000 egresos. Mediana de edad 54 meses; tenían patología crónica previa 11,2%. Tuvieron factores predisponentes 67,1%. Las formas de presentación más frecuentes fueron la piel y las partes blandas en 77, sepsis en 30, osteoarticulares en 19, fascitis necrotizante en 13, síndrome de shock tóxico en 11. Se aisló Streptococcus pyogenes en 56,6% de los hemocultivos; la presencia de más de un foco clínico y la ausencia de cirugía se asociaron a bacteriemia (OR 4,8; p= 0,003 y OR 3,1; p= 0,0012, respectivamente). El promedio de internación fue 13,4 días. La tasa de letalidad fue 7,6% asociada a síndrome de shock tóxico (OR 10; p= 0,005), fascitis necrotizante (OR 104; p < 0,0001) e ingreso a la Unidad de Cuidados Intensivos Pediátricos (OR 26; p < 0,001). Conclusiones. La mayoría de las IISP se presentaron en pacientes sin patología crónica previa. Los focos de presentación, frecuentemente con bacteriemia, fueron la piel y las partes blandas. Hubo asociación estadísticamente significativa entre bacteriemia y ≥ 2 focos iniciales y ausencia de cirugía. La letalidad, asociada a SSTS y fascitis necrotizante, fue similar a otras publicaciones.

Introduction. Invasive Streptococcus pyogenes infections (ISpIs) cause a high morbidity and mortality, even at present; however, at a regional level there are few publications on this subject in the field of pediatrics. Objective. To describe the prevalence, predisposing factors and clinical characteristics of children hospitalized for ISpI, and analyze risk factors associated with bacteremia and lethality. Material and methods. Retrospective, descriptive study on ISpIs in children <18 years old hospitalized in the Pediatric Ward of 20 healthcare facilities across Argentina between 2010 and 2012. Assessed outcome measures: age, gender, early and late clinical sources of infection, prior chronic condition, predisposing factors, treatment and evolution. Results. One hundred and forty-three patients were analyzed. The incidence of ISpI was 4.97 cases/10 000 hospital discharges. Patients' median age was 54 months old, and 11.2% had a prior chronic condition. Also, 67.1% had predisposing factors. The most common clinical manifestations were in the skin and soft tissue in 77 patients, sepsis in 30, bone and joint involvement in 19, necrotizing fasciitis in 13, and toxic shock syndrome in 11. Streptococcus pyogenes was isolated in the blood cultures of 56.6%. More than one clinical source of infection and no surgery were associated with bacteremia (odds ratio [OR]: 4.8, p= 0.003 and OR: 3.1, p= 0.0012, respectively). The average length of stay in the hospital was 13.4 days. Fatality rate was 7.6% in association with toxic shock syndrome (OR: 10, p= 0.005), necrotizing fasciitis (OR: 104, p < 0.0001) and admission to the Pediatric Intensive Care Unit (OR: 26, p < 0.001). Conclusions. Most ISpIs were observed in patients without a prior chronic condition. The most common manifestation was, frequently with bacteremia, in the skin and soft tissue. A statistically significant association was observed between bacteremia and ≥2 early sources of infection and no surgery. Fatality rate, in association with streptococcal toxic shock syndrome and necrotizing fasciitis, was similar to that observed in other publications.

Multicenter study on invasive Streptococcus pyogenes infections in children in Argentina. / Estudio multicéntrico de infecciones invasivas por Streptococcus pyogenes en niños de Argentina.

INTRODUCTION: Invasive Streptococcus pyogenes infections (ISpIs) cause a high morbidity and mortality, even at present; however, at a regional level there are few publications on this subject in the field of pediatrics. OBJECTIVE: To describe the prevalence, predisposing factors and clinical characteristics of children hospitalized for ISpI, and analyze risk factors associated with bacteremia and lethality. Material and methods. Retrospective, descriptive study on ISpIs in children <18 years old hospitalized in the Pediatric Ward of 20 healthcare facilities across Argentina between 2010 and 2012. Assessed outcome measures: age, gender, early and late clinical sources of infection, prior chronic condition, predisposing factors, treatment and evolution. RESULTS: To describe the prevalence, predisposing factors and clinical characteristics of children hospitalized for ISpI, and analyze risk factors associated with bacteremia and lethality. Material and methods. Retrospective, descriptive study on ISpIs in children <18 years old hospitalized in the Pediatric Ward of 20 healthcare facilities across Argentina between 2010 and 2012. Assessed outcome measures: age, gender, early and late clinical sources of infection, prior chronic condition, predisposing factors, treatment and evolution. CONCLUSIONS: Most ISpIs were observed in patients without a prior chronic condition. The most common manifestation was, frequently with bacteremia, in the skin and soft tissue. A statistically significant association was observed between bacteremia and ≥2 early sources of infection and no surgery. Fatality rate, in association with streptococcal toxic shock syndrome and necrotizing fasciitis, was similar to that observed in other publications.

INTRODUCCIÓN: Las infecciones invasivas por Streptococcus pyogenes (IISP) presentan elevada morbimortalidad aún en la actualidad; no obstante, a nivel regional, existen escasas publicaciones en pediatría. OBJECTIVO: Describir la prevalencia, los factores predisponentes y las características clínicas de niños internados por IISP, analizar los factores de riesgo asociados a bacteriemia y letalidad. Material y métodos. Estudio retrospectivo, descriptivo de IISP en niños ≤ 18 anos, internados en Pediatría de 20 centros asistenciales del país, entre 2010 y 2012. Variables evaluadas: edad, sexo, focos clínicos iniciales y tardíos, patología crónica previa, factores predisponentes, tratamiento y evolución. RESULTADOS: Se analizaron 143 pacientes. Incidencia de 4,97 casos/10 000 egresos. Mediana de edad 54 meses; tenían patología crónica previa 11,2%. Tuvieron factores predisponentes 67,1%. Las formas de presentación más frecuentes fueron la piel y las partes blandas en 77, sepsis en 30, osteoarticulares en 19, fascitis necrotizante en 13, síndrome de shock tóxico en 11. Se aisló Streptococcus pyogenes en 56,6% de los hemocultivos; la presencia de más de un foco clínico y la ausencia de cirugía se asociaron a bacteriemia (OR 4,8; p= 0,003 y OR 3,1; p= 0,0012, respectivamente). El promedio de internación fue 13,4 días. La tasa de letalidad fue 7,6% asociada a síndrome de shock tóxico (OR 10; p= 0,005), fascitis necrotizante (OR 104; p < 0,0001) e ingreso a la Unidad de Cuidados Intensivos Pediátricos (OR 26; p < 0,001). CONCLUSIONES: La mayoría de las IISP se presentaron en pacientes sin patología crónica previa. Los focos de presentación, frecuentemente con bacteriemia, fueron la piel y las partes blandas. Hubo asociación estadísticamente significativa entre bacteriemia y ≥ 2 focos iniciales y ausencia de cirugía. La letalidad, asociada a SSTS y fascitis necrotizante, fue similar a otras publicaciones.

[Necrotizing fasciitis, myositis, arthritis, and streptococcal toxic shock syndrome caused by group G Streptococcus. Report of one case]. / Fascitis necrotizante, miositis y síndrome de choque tóxico secundario a estreptococo del grupo G. Reporte de un caso.

BACKGROUND: Necrotizing fasciitis (NF), myositis, and streptococcal toxic shock syndrome (STSS) associated with group G ß-hemolytic streptococcus (GGS) occasionally coincide. CLINICAL CASE: We describe a case of GGS simultaneously occurring with NF, myositis, arthritis, and STSS in an 83-year-old woman with sequelae of cerebrovascular disease, hospitalized after two days of fever and with a painful swollen left foot. She was hypotensive, her foot had purplish discoloration, which showed blisters spreading to the lower third of the leg, and no crepitus was present. Fluid, vasopressive support, tigecyclin, and clindamycin were used. Debrided tissue and fluid aspirated from the knee joint revealed Gram-positive cocci. The patient developed renal and respiratory failure on the fifth day, requiring support. She underwent amputation above the knee of the left leg, after which her condition improved. She was discharged one month later. CONCLUSION: GGS can cause life-threatening infections such as NF, myositis, and/or STSS. GGS usually afflicts aging patients with comorbid states, and occasionally healthy subjects.

Introducción: ocasionalmente concurren la fascitis necrotizante (FN), con miositis, y síndrome de choque tóxico post-estreptocócico (SSTE) asociados con infección por estreptococo ß-hemolítico del grupo G (EGG). Caso clínico: presentamos un caso de infección en el que concurren simultáneamente FN, miositis, artritis y SSTE en una mujer de 83 años con secuelas de enfermedad cerebrovascular, hospitalizada tras dos días de fiebre y dolor, así como hinchazón del pie izquierdo. Se encontraba hipotensa y el pie mostraba coloración púrpura con flictenas que se extendían hacia el tercio inferior de la pierna; no había crepitación a la presión digital. Se empleó hidratación parenteral, vasopresores, tigeciclina y clindamicina. Tanto el tejido desbridado como el líquido aspirado de la articulación de la rodilla revelaron cocos gram positivos. Al quinto día la paciente desarrolló falla renal y respiratoria que requirieron de apoyo. La paciente fue sometida a amputación supracondílea de la pierna izquierda; después de eso, su condición mejoró. Un mes después fue dada de alta. Conclusiones: el EGG puede causar infecciones potencialmente mortales, como FN, miositis, y/o SSTE. El EGG por lo general afecta a pacientes ancianos con estados comórbidos y ocasionalmente a sujetos sanos.

Ocorrência do gene da toxina da síndrome do choque tóxico em Staphylococcus spp. isolados de leite de vacas com mastite e de leite cru refrigerado / Occurrence of the toxic shock syndrome toxin gene in Staphylococcus spp.isolated from bovine mastitis milk and refrigerated raw milk

Avaliou-se a presença do gene (tst-1) para Toxina da Síndrome do Choque Tóxico-1 (TSST-1), utilizando-se a técnica de Reaçãoem Cadeia da Polimerase (PCR) em um total de 264 Staphylococcus spp. isolados de leite. Desses, 221 eram Staphylococcusaureus, 33 Staphylococcus coagulase negativo (SCN) e 10 Staphylococcus coagulase positivo (SCP). As amostras eram oriundasde vacas com mastite (n=96) e de leite cru refrigerado (n=168), coletadas de 46 e 22 propriedades, respectivamente. As amostrasforam coletadas de rebanhos localizados em diferentes regiões dos Estados de Minas Gerais e Rio de Janeiro. Observou-seproduto de amplificação (250 pares de base-pb) na reação de PCR para tst-1 em sete amostras (2,6%), sendo todas as estirpesidentificadas como Staphylococcus aureus isoladas de leite cru refrigerado. Embora a detecção do gene não indique a produçãoda toxina, o monitoramento de estirpes bacterianas potencialmente produtoras torna-se importante como forma de realizar umlevantamento epidemiológico e controle dos rebanhos leiteiros brasileiros, uma vez que esse gene está associado aos elementosgenéticos móveis, representando um risco à possível transferência horizontal de genes para outras bactérias. Além disso, a presençadesses genes tem sido associada à presença de genes para enterotoxinas estafilocócicas, o que pode implicar o aumento dapatogenicidade dos isolados bacterianos e um potencial risco à saúde pública.(AU)

Was evaluated the presence of the gene (tst -1) for toxic shock syndrome toxin - 1 (TSST -1), using the technique of PolymeraseChain Reaction (PCR) on a total of 264 Staphylococcus spp. isolated from milk. Of these, 221 were Staphylococcus aureus, 33Staphylococcus coagulase negative (SCN) and 10 Staphylococcus coagulase positive (SCP). The samples were from cows withmastitis (n=96) and refrigerated raw milk (n=168), collected from 46 and 22 dairy herds, respectively. Samples were collectedfrom herds located in different regions of Minas Gerais and Rio de Janeiro States. Was observed PCR amplification of the tst-1gene (250 base pairs-bp) in seven (2.6 %) samples, and all strains of Staphylococcus aureus isolated from refrigerated raw milk.Although its detection in isolated does not mean that it will be expressed, monitoring of bacterial strains producing potentiallybecomes important as performing an epidemiological survey and control of Brazilian dairy herds, since this gene is associatedwith mobile genetic elements, representing a risk to possible horizontal gene transfer to other bacteria. Furthermore, the presenceof these genes have been associated with the presence of genes for enterotoxins, which may result in increased pathogenicity ofthe isolates and a potential risk to public health.(AU)

Ocorrência do gene da toxina da síndrome do choque tóxico em Staphylococcus spp. isolados de leite de vacas com mastite e de leite cru refrigerado / Occurrence of the toxic shock syndrome toxin gene in Staphylococcus spp.isolated from bovine mastitis milk and refrigerated raw milk

Avaliou-se a presença do gene (tst-1) para Toxina da Síndrome do Choque Tóxico-1 (TSST-1), utilizando-se a técnica de Reaçãoem Cadeia da Polimerase (PCR) em um total de 264 Staphylococcus spp. isolados de leite. Desses, 221 eram Staphylococcusaureus, 33 Staphylococcus coagulase negativo (SCN) e 10 Staphylococcus coagulase positivo (SCP). As amostras eram oriundasde vacas com mastite (n=96) e de leite cru refrigerado (n=168), coletadas de 46 e 22 propriedades, respectivamente. As amostrasforam coletadas de rebanhos localizados em diferentes regiões dos Estados de Minas Gerais e Rio de Janeiro. Observou-seproduto de amplificação (250 pares de base-pb) na reação de PCR para tst-1 em sete amostras (2,6%), sendo todas as estirpesidentificadas como Staphylococcus aureus isoladas de leite cru refrigerado. Embora a detecção do gene não indique a produçãoda toxina, o monitoramento de estirpes bacterianas potencialmente produtoras torna-se importante como forma de realizar umlevantamento epidemiológico e controle dos rebanhos leiteiros brasileiros, uma vez que esse gene está associado aos elementosgenéticos móveis, representando um risco à possível transferência horizontal de genes para outras bactérias. Além disso, a presençadesses genes tem sido associada à presença de genes para enterotoxinas estafilocócicas, o que pode implicar o aumento dapatogenicidade dos isolados bacterianos e um potencial risco à saúde pública.

Was evaluated the presence of the gene (tst -1) for toxic shock syndrome toxin - 1 (TSST -1), using the technique of PolymeraseChain Reaction (PCR) on a total of 264 Staphylococcus spp. isolated from milk. Of these, 221 were Staphylococcus aureus, 33Staphylococcus coagulase negative (SCN) and 10 Staphylococcus coagulase positive (SCP). The samples were from cows withmastitis (n=96) and refrigerated raw milk (n=168), collected from 46 and 22 dairy herds, respectively. Samples were collectedfrom herds located in different regions of Minas Gerais and Rio de Janeiro States. Was observed PCR amplification of the tst-1gene (250 base pairs-bp) in seven (2.6 %) samples, and all strains of Staphylococcus aureus isolated from refrigerated raw milk.Although its detection in isolated does not mean that it will be expressed, monitoring of bacterial strains producing potentiallybecomes important as performing an epidemiological survey and control of Brazilian dairy herds, since this gene is associatedwith mobile genetic elements, representing a risk to possible horizontal gene transfer to other bacteria. Furthermore, the presenceof these genes have been associated with the presence of genes for enterotoxins, which may result in increased pathogenicity ofthe isolates and a potential risk to public health.

Infección por Staphyloccus aureus resistente a la meticillina adquirido en la comunidad (SAMR-AC) / Community-acquired methicillin-resistant Staphylococcus aureus infection (CA-MRSA

Se presenta un paciente de 1 año de edad con antecedentes de salud, que desarrolló infección estafilocócica de piel y partes blandas, que lo llevó al desarrollo de shock tóxico, disfunción múltiple de órganos y muerte. Se aisló en cultivo de tejido pulmonar posmorten cepa de Staphylococcus aureus resistente a la meticillina, productor de la toxina Panton-Valantine leucocidina demostrado por caracterización molecular. Se estableció el diagnóstico anatomopatológico de sepsis generaliza y bronconeumonía necrosante bilateral(AU)

A one-year old patient with history of health problems, who developed Staphylococcus aureus-caused infection in the skin and soft tissues that led him to toxic shock, multiple organ failure and death. Methilline-resistant Staphylococcus aureus strain was isolated in pulmonary tissue culture after death. This strain produced Panton-Valantine toxin called leukocidin as proved in molecular characterization. There was established the anatomic-pathological diagnosis of generalized sepsis and bilateral necrosing bronchopneumonia(AU)

Infección por Staphyloccus aureus resistente a la meticillina adquirido en la comunidad (SAMR-AC) / Community-acquired methicillin-resistant Staphylococcus aureus infection (CA-MRSA)

Se presenta un paciente de 1 año de edad con antecedentes de salud, que desarrolló infección estafilocócica de piel y partes blandas, que lo llevó al desarrollo de shock tóxico, disfunción múltiple de órganos y muerte. Se aisló en cultivo de tejido pulmonar posmorten cepa de Staphylococcus aureus resistente a la meticillina, productor de la toxina Panton-Valantine leucocidina demostrado por caracterización molecular. Se estableció el diagnóstico anatomopatológico de sepsis generaliza y bronconeumonía necrosante bilateral.

A one-year old patient with history of health problems, who developed Staphylococcus aureus-caused infection in the skin and soft tissues that led him to toxic shock, multiple organ failure and death. Methilline-resistant Staphylococcus aureus strain was isolated in pulmonary tissue culture after death. This strain produced Panton-Valantine toxin called leukocidin as proved in molecular characterization. There was established the anatomic-pathological diagnosis of generalized sepsis and bilateral necrosing bronchopneumonia.

Síndrome de shock tóxico neonatal por Streptococcus pyogenes: Reporte de caso y revisión de la literatura / Neonatal toxic shock syndrome due to Streptococcus pyogenes: Case report and literature review

Se realizó un resumen de la historia clínica de un recién nacido (RN) fallecido por síndrome de shock tóxico (SST) a Streptococcus pyogenes y se revisó la literatura existente al respecto mediante la búsqueda en distintas bases de datos y otras fuentes. Previo a nuestro paciente se han publicado seis RNs con SST por S. pyogenes con la descripción clínica de los mismos y otros tres RNs sin información detallada de los casos. Se concluye que, en la actualidad, la infección por S. pyogenes no es ya un flagelo en el período neonatal, pero cuando se presenta, puede provocar SST con elevada letalidad.

The clinical history of a newborn child who died from toxic shock syndrome (TSS) due to group A Streptococcus (GAS) was summarized. Literature was reviewed by searching different databases and other sources. Previous to our patient, there were 6 neonatal patients with TSS due to GAS published with the clinical description of the cases and three others without detailed information. In conclusion, nowadays, infection due to GAS is not a frequent devastating disease during the neonatal period, but when it is present it can cause TSS with high lethality.

Use of pcr to detect classical enterotoxins genes (ent) and toxic shock syndrome toxin-1 gene (tst) in staphylococcus aureus isolated from crude milk and determination of toxin productivities of s. aureus isolates harboring these genes

ABSTRACT During a 2-year period (2003-2004), 132 strains of Staphylococcusaureus isolated from crude milk (without thermal treatment) collected in different places in Piracicaba, São Paulo State, Brazil, were investigated for the presence of genes for enterotoxins (ent) and toxic shock syndrome toxin-1 (tst). Polymerase-chain reaction (PCR) was performed by using 6 pairs of relevant oligonucleotide primers. Ninety isolates (68.18%) were positive for (47 strains) or 2 (43 strains) toxin genes. The combination of entA and tst showed the highest prevalence (33 strains).The good correlation between PCR results and toxin protein detection and identification by optimum-sensitivity-plate (OSP) test was observed when 44.45% of strains showed positive for toxin production.

RESUMO Durante um período de 2 anos (20032004), 132 cepas de Staphylococcus aureus isoladas de leite cru foram coletadas de diferentes regiões de Piracicaba, no Estado de São Paulo. Foi investigada a presença dos genes de enterotoxinas (ent) e genes da Toxina-1 da Síndrome do Choque Tóxico (tst). A reação da polimerase em cadeia (PCR) foi executada usando 6 pares de oligonucleotídeos específicos para cada gene em questão. Noventa e quatro isolados (68,18%) se mostraram positivos para a presença de um (47 isolados) ou mais genes (43 isolados). A combinação da presença de entA e tst mostrou alta prevalência (33 isolados). Houve boa correlação entre a presença do gene e a produção/detecção da toxina, feita pelo teste da sensibilidade ótima em placas (OSP), que foi observada quando 44,44% dos isolados mostraramse positivos para a produção de toxina.