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Toxic shock syndrome: under-recognised and under-treated?
  1. Nigel Curtis
  1. Correspondence to Department of Paediatrics, The University of Melbourne; Murdoch Children's Research Institute; and Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia; nigel.curtis{at}

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Toxic shock syndrome (TSS) is a relatively rare but severe disease that is more common in children than adults and characterised by fever, erythematous rash and multiorgan failure. In this month's edition, Adalat and colleagues1 report the results from a British Paediatric Surveillance Unit study of TSS in the UK and RI.

TSS is caused by exotoxins, produced by Staphylococcus aureus and Streptococcus pyogenes (group A streptococci), that are superantigens capable of initiating an uncontrolled inflammatory cascade. Pro-inflammatory cytokines acting on the vascular endothelium cause capillary leak that can ultimately result in hypotension with consequent multiorgan failure. This process, induced by superantigen toxins from Gram-positive bacteria, is similar to, but distinct from, the inflammatory cascade initiated by endotoxin in Gram-negative shock. The term TSS was coined by Dr Jim Todd when he first described the condition in children in 1978. Children are generally more susceptible to TSS as they are more likely to lack protective antibodies against the causative toxins.

Adalat et al found an incidence of TSS in the UK and RI of 0.3 per 100 000 children. Their findings confirm some of the known risk factors for TSS, such as chickenpox and other conditions that compromise the integrity of the skin barrier. However, a surprising finding was the low incidence of burn-related cases and of cases associated with flu, despite the survey period including the H1N1 epidemic. Most importantly, the study highlights the difficulties in recognising and identifying cases of TSS and raises concerns about the management of this condition in the UK and RI.

There are a number of reasons to believe that the low incidence of TSS determined in this study is an underestimate. Aside from the unavoidable limitations of voluntary surveillance, TSS cases may be missed as the diagnosis relies on the treating clinician recognising …

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  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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