What Was Observed? (Introduction)

• Recent changes in the pattern of disease caused by Group A β-hemolytic streptococcus (GABHS) were noted.
• A toxic shock-like syndrome, similar to that seen with Staphylococcus aureus, has been observed in both adults and children.
• Four children developed a rapid-onset illness characterized by shock, an erythematous (red) rash, multisystem organ involvement, electrolyte imbalances, and skin peeling (desquamation).
• Three children had extensive skin and soft tissue infections, while one had peritonitis (infection of the abdominal lining).
• GABHS was isolated from the blood in all cases, confirming a bloodstream infection (bacteremia).

What is Group A β-hemolytic Streptococcus (GABHS)?

• GABHS is a type of bacteria that can cause illnesses ranging from mild infections (like strep throat) to severe conditions such as toxic shock syndrome.
• In this study, GABHS is linked to a toxic shock syndrome in children.

What is Toxic Shock Syndrome (TSS)?

• TSS is a severe, life-threatening condition caused by bacterial toxins triggering an overwhelming immune response.
• It is characterized by high fever, a widespread rash, very low blood pressure (shock), and failure of multiple organs.
• Traditionally associated with Staphylococcus aureus, but in these cases it is linked to GABHS.

Who Were the Patients? (Patients and Methods)

• Four children were diagnosed between February 1988 and November 1990.
• The cases included:
  • A 10-year-old girl
  • A 22-month-old girl
  • A 13-day-old girl
  • A 10-week-old girl
• All met the diagnostic criteria for toxic shock syndrome, but instead of Staphylococcus aureus, GABHS was isolated from their blood.
• Infection sites varied: skin wounds, cellulitis (a skin infection), and peritonitis.

How Did They Get Sick? (Case Reports – Simplified)

• Case 1: 10-year-old girl
  • Started with a cut below the knee, followed by pain and swelling in the ankles.
  • Developed a general red rash and fever, then rapidly progressed to shock (low blood pressure and high heart rate).
  • Experienced severe soft tissue infection (fasciitis – infection of the connective tissue under the skin), leading to tissue death.
  • Required aggressive fluid resuscitation, heart support medications, mechanical ventilation, and eventually an amputation of the right upper limb below the elbow.
  • Her organ functions gradually recovered after treatment.
• Case 2: 22-month-old girl
  • Initially had cough, fever, and mild facial swelling.
  • Developed red blister-like lesions (bullae) on the trunk and limbs.
  • Rapid progression to shock led to aggressive fluid resuscitation and antibiotic treatment.
  • Imaging showed a neck mass with inflammation; surgical exploration was performed and treatment was adjusted.
  • Skin peeling appeared around day 8, and she was discharged after two weeks.
• Case 3: 13-day-old girl
  • Presented with a red rash, diarrhea, vomiting, and refusal to feed.
  • Quickly developed signs of shock and poor blood circulation; her abdomen became swollen and rigid, suggesting peritonitis.
  • Underwent a surgical procedure (laparotomy – opening of the abdomen) to check for infection.
  • Received high-dose penicillin; experienced prolonged skin peeling and intermittent fever.
  • After 22 days in hospital and further recovery, she was eventually discharged.
• Case 4: 10-week-old girl
  • Initially developed pallor (pale skin) and low body temperature.
  • A small red lesion under the jaw became hard, swollen, and spread to both sides of the neck.
  • Rapidly progressed to shock with high heart rate and low blood pressure, requiring immediate fluid resuscitation and mechanical ventilation.
  • Experienced metabolic acidosis (excess acidity in body fluids) and seizures; blood cultures confirmed GABHS infection.
  • With supportive care and antibiotics, the shock resolved and she was discharged on day 14.

Treatment Steps:

• Aggressive fluid resuscitation: Large amounts of intravenous fluids to restore blood pressure.
• Inotropic support: Medications to help the heart pump more effectively.
• Mechanical ventilation: Use of a breathing machine when necessary.
• Antibiotic therapy: High-dose penicillin (the drug of choice for GABHS) combined with other antibiotics as needed.
• Surgical intervention: Procedures to remove infected tissue, drain abscesses, and relieve pressure (such as fasciotomy, which is the surgical release of pressure in muscles).

Outcomes and Complications:

• No deaths occurred, but all patients experienced severe complications.
• Complications included:
  • Tissue death leading to amputation (Case 1)
  • Compartment syndrome: Increased pressure in muscle compartments causing further tissue damage.
  • Prolonged fever and slow recovery.
  • Extended hospital stays and intensive treatment.
• With early and aggressive treatment, normal organ function was eventually restored in all children.

Key Conclusions (Discussion):

• Streptococcal toxic shock syndrome is a distinct, severe condition occurring in previously healthy children.
• It differs from staphylococcal toxic shock syndrome in several ways:
  • It is caused by Group A streptococcus instead of Staphylococcus aureus.
  • It is usually associated with severe local infections and bacteremia (bacteria in the blood).
  • Skin peeling may be less frequent and the rash can appear later in the illness.
  • More frequent surgical intervention is often needed due to extensive soft tissue infection.
• The condition is thought to be triggered by toxins produced by GABHS, known as superantigens, which can overactivate the immune system like an overzealous alarm system.
• Early recognition and aggressive management are crucial to prevent fatal outcomes.
• An increase in severe GABHS infections has been noted in recent years.

观察到了什么？ (引言)

• 近期观察到A组β溶血性链球菌（GABHS）引起的疾病谱发生了变化，出现了一种类似中毒性休克综合征的新症候群。
• 这种中毒性休克综合征与传统的金黄色葡萄球菌相关TSS不同，而是由GABHS引起。
• 四名患儿出现了休克、红斑、多个器官受累、电解质紊乱及皮肤脱屑等症状，病情进展迅速。
• 其中三名患儿伴有广泛的皮肤和软组织感染，一名患儿出现腹膜炎（腹腔内膜感染）。
• 所有病例中血液培养均检出GABHS，证实存在菌血症（血液中细菌）。

什么是A组β溶血性链球菌 (GABHS)？

• GABHS是一种细菌，可引起从轻微感染（如链球菌性咽炎）到严重疾病（如中毒性休克）的多种感染。
• 本研究中，GABHS与儿童中出现的中毒性休克综合征有关。

什么是中毒性休克综合征 (TSS)？

• 中毒性休克综合征是一种由细菌毒素触发全身性免疫反应引起的严重、危及生命的疾病。
• 其特点包括高热、全身性皮疹、极低血压（休克）以及多个器官功能衰竭。
• 传统上与金黄色葡萄球菌有关，但此处与GABHS相关。

患者是谁？ (患者与方法)

• 四名患儿于1988年2月至1990年11月期间被诊断出中毒性休克综合征。
• 病例包括：
  • 一名10岁女孩
  • 一名22个月女孩
  • 一名13天大女孩
  • 一名10周大女孩
• 所有患儿均符合中毒性休克综合征的诊断标准，但血液培养中均分离出GABHS，而非金黄色葡萄球菌。
• 感染部位各不相同，包括皮肤伤口、蜂窝织炎（皮肤感染）和腹膜炎等。

他们是如何生病的？ (病例报告 – 简化版)

• 病例1：10岁女孩
  • 最初在膝盖以下受伤后出现踝部疼痛和肿胀。
  • 随后出现全身性红斑、发热，并迅速进展为休克（低血压和高心率）。
  • 出现严重的软组织感染（筋膜炎，即皮下结缔组织感染），导致组织坏死。
  • 接受大量液体复苏、心脏支持药物、机械通气，最终右上肢低于肘部截肢。
  • 经过治疗后，器官功能逐步恢复。
• 病例2：22个月女孩
  • 初期症状包括咳嗽、发热和轻度面部肿胀。
  • 随后躯干和四肢出现多个红色水疱样病变。
  • 病情迅速进展为休克，接受大量液体复苏和抗生素治疗。
  • 影像检查显示颈部有炎症性肿块，经过手术探查和治疗调整后情况改善。
  • 大约在第8天出现皮肤脱屑，两周后出院。
• 病例3：13天大女孩
  • 出现红斑、腹泻、呕吐及拒食等症状。
  • 病情迅速恶化，出现休克和血液循环不良；腹部肿胀僵硬，疑似腹膜炎。
  • 进行了开腹手术（腹部切开检查）以排除腹部感染。
  • 接受高剂量青霉素治疗，并出现长时间皮肤脱屑和反复发热。
  • 经过22天住院治疗及后续恢复，病情最终稳定并康复。
• 病例4：10周大女孩
  • 最初出现苍白和低体温，随后左下颌出现红色病灶，逐渐硬化、肿胀并扩散至双侧颈部。
  • 病情迅速进展为休克，出现高心率和低血压，紧急接受大量液体复苏和机械通气。
  • 出现代谢性酸中毒（体液酸度过高）及局部癫痫发作，血液培养确认GABHS感染。
  • 经过抗生素及支持治疗，休克状况逐步缓解，第二天停止机械通气，并于第14天出院。

治疗步骤：

• 积极液体复苏：大量静脉输液以恢复血压。
• 心脏支持：使用正性肌力药物帮助心脏更有效地泵血。
• 机械通气：必要时使用呼吸机辅助呼吸。
• 抗生素治疗：使用高剂量青霉素（GABHS的首选药物）联合其他抗生素。
• 外科干预：通过手术清除感染组织、引流脓液及解除肌肉内压力（筋膜切开术）以减少毒素释放。

结果与并发症：

• 所有患儿均未死亡，但都经历了严重并发症。
• 并发症包括：
  • 组织坏死，导致截肢（如病例1）。
  • 筋膜室综合征：肌肉间压力过高，进一步损害组织。
  • 持续高热和缓慢康复过程。
  • 长时间住院及需要密集治疗。
• 通过早期和积极的治疗，所有患儿最终恢复了正常器官功能。

主要结论 (讨论):

• 链球菌相关的中毒性休克综合征是一种发生在先前健康儿童中的独特且严重的疾病。
• 与金黄色葡萄球菌相关的中毒性休克综合征相比，此病有以下区别：
  • 病原体为A组链球菌，而非金黄色葡萄球菌。
  • 通常伴有严重的局部感染和菌血症（血液中细菌存在）。
  • 皮肤脱屑较少见，且皮疹可能在病程后期出现。
  • 因广泛软组织感染，外科手术干预更为常见。
• 病症可能由链球菌产生的毒素（超抗原）引起，这些毒素能过度激活免疫系统，就像误触发的警报系统一样。
• 早期识别与积极治疗对预防致命结局至关重要。
• 近年来，严重GABHS感染的发生率有所上升，需引起临床重视。