The Nose Knows: Toxic Shock and Rhinosinusitis

Abstract

Source: Chan KH, Kraai TL, Richter GT, et al. Toxic shock syndrome and rhinosinusitis in children. Arch Otolaryngology Head Neck Surgery. 2009;135:538–542; doi:10.1001/archoto.2009.55Investigators from The Children’s Hospital, Denver, sought to determine the relationship between toxic shock syndrome (TSS) in children and either acute or chronic rhinosinusitis. To identify potential study patients, the primary and secondary discharge diagnoses of children admitted between 1983 and 2000 were searched using diagnostic codes for TSS and sinusitis. Medical records of the identified children were reviewed.TSS was defined as fever (>38.9°C), a diffuse macular erythroderma (with or without desquamation), hypotension, and dysfunction of three or more body systems.1 Proven TSS included all four criteria, while probable TSS cases fulfilled three of the four criteria. Probable rhinosinusitis was defined as plain or CT films with ≥4 mm of mucosal thickening in the maxillary sinuses, air fluid levels in any of the sinuses, or total opacification of any of the paranasal sinuses. Proven rhinosinusitis required the same abnormal radiographic imaging plus a positive culture or Gram stain for organisms or polymorphonuclear cells.A total of 11 cases of proven TSS and five probable TSS with either proven or probable rhinosinusitis were identified. The average age was 10 years with equal distribution of girls and boys. Ten of these children required critical care while six underwent otolaryngologic surgery. No patients died. The authors conclude that patients with TSS without an identified source of infection should be evaluated for sinus disease.Dr Lemoine has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.TSS is an acute, toxin-mediated illness, and like endotoxic shock, is characterized by fever, rash, hypotension, multi-organ involvement, and desquamation.2 TSS is usually caused by Staphylococcus aureus or Streptococcus pyogenes. The mortality in children is slightly higher with streptococcal TSS (5–10%) compared to staphylococcal TSS (3–5%).3 TSS appears to be a rare complication of sinus disease. The limited number of sinus cultures performed in children with TSS and sinusitis precludes any conclusions regarding the causative organisms. The principal bacterial pathogens of acute bacterial rhinosinusitis are S pneumoniae (30%–40%), Haemophilus influenzae (20%–30%), Moraxella catarrhalis (12%–20%), and S pyogenes (up to 3%).5 Other pathogens include other Streptococcus species, Staphylococcus aureus, and Neisseria species. Rhinosinusitis complicates 5%–10% of pediatric upper respiratory infections and typically is a self-limiting disease.4This case series suggests that sinus disease should be evaluated in children with TSS and no identified source of infection. However, the authors did not reach any conclusions as to the frequency of sinus disease as an infectious source for TSS or the merits of antral lavage, performed in five patients in this report. The utility of surgery to treat rhinosinusitis in children with TSS awaits further investigation.TSS was first described as a unique entity associated with S aureus in 1978 by J. Todd, one of the coauthors of this paper.8 Subsequent interest in the syndrome, generated by its association with tampon use in young women, relegated to virtual obscurity the fact that all seven patients in the original report were children. Unfortunately, estimates of the current frequency and age distribution of TSS are undoubtedly inaccurate as they rely on passive surveillance.9 The disease has been reported in all age groups, but is most common in children and young adults who presumably lack immunity to toxic shock syndrome toxin-1 (TSST-1).Approximately 50% of reported cases are now unrelated to menses. TSS has been associated with surgical wounds, cutaneous and subcutaneous infections, adenitis, bursitis, osteomyelitis, burns, and respiratory and post-partum infections.10 This study reminds us of the previous reports of TSS associated with nasal packing10,11 but unfortunately it lacks bacteriologic confirmation. Nonetheless, it serves as a reminder of the myriad anatomic sites in which the organisms can replicate and release toxins.