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Pediatric Toxic Shock Syndrome After a 7% Burn: A Case Study and Systematic Literature Review
Khajuria A, Nadama HH, Gallagher M, Jones I, Atkins J
Annals of plastic surgery. 2019
Abstract
INTRODUCTION Toxic shock syndrome (TSS) is a life-threatening condition, which occurs in children after sustaining a burn. Often diagnosed retrospectively, many patients may not receive optimal treatment.The primary objective of this study was to evaluate a severe and complex case of TSS at our unit and subsequently conduct a Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review, to identify cases of postthermal injury TSS and evaluate their presentation and management. CASE REPORT A 9-year-old boy with Down syndrome presented with a 7% total body surface area scald to his back and posterior head. Four days after discharge, he developed a fever. The following day, he deteriorated, becoming stridulous and unresponsive. A working diagnosis of TSS was made. The patient's intensive care stay was arduous with multiple complications, including 2 cardiac arrests. METHODS A Preferred Reporting for Systematic Reviews and Meta-Analyses-compliant systematic literature review was conducted. MEDLINE, PubMed, and Web of Science were searched using key terms "burns, thermal injury, scalds, paediatric, child, infant, neonate, toxic shock syndrome" to identify cases. Two authors independently checked each study against inclusion criteria. RESULTS The systematic literature search yielded 9 articles, identifying 40 cases. Ages ranged between 9 months and 8 years. The mean number of days' postburn patients presented with symptoms of TSS was 2.5 days (1-7 days). The most common presenting symptoms were fever (75%), rash (70%), and diarrhea, and/or vomiting (52.5%). Intravenous immunoglobulins were administered in 11 (27.5%) cases. DISCUSSION We have highlighted a case where a possible delayed diagnosis along with the immunodeficiency seen in Down syndrome may have impacted the severity of TSS. The literature review highlighted that a significant proportion of patients do not meet diagnostic criteria. CONCLUSIONS It is fundamental that appropriate diagnostic and management guidelines are developed. Furthermore, this case highlights the importance of educating patient's carers and health professionals of key symptoms to be wary of postburn.
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2.
Serum IgG concentrations and antibody titer of burn patients after preventive intravenous IgG substitution with a Pseudomonas immunoglobulin German
Stuttmann R, Hartert M, Jahn M, Spilker G, Doehn M
Infusionstherapie und Transfusionsmedizin. 1993;20((Suppl 1):):48-55.
Abstract
In a randomized clinical trial 30 patients with burn injury received supportive therapy with a Pseudomonas hyperimmunoglobulin (Psomaglobin N). The control group received no additional therapy. The patients of both groups were between 15 and 60 years of age and had a full-thickness burn of 30-70% of the body surface area with inhalational trauma being optional. The whole trauma was classified and scored with the 'Abbreviated Burn Severity Index' (which allows another extra score point for inhalational trauma). Both groups underwent the same intensive care unit treatment with preference to early wound excision and wound grafting following functional aspects of reconstructive surgery. Bacteriological monitoring was performed on suspicion of wound infection and bacteremia by taking wound swabs and blood cultures. The supportive treatment group received a total of 250 mg/kg hyperimmunoglobulin on days 3, 5, 7, 10, and 13. Of 30 patients in the control group 16 had an additional inhalation trauma, and 8 of those (50%) died (only 1 of 14 patients without inhalation trauma died). In the group receiving supportive treatment, 23 out of 30 patients had an inhalation trauma, and 8 of those (35%) died (1 of 7 patients without inhalation trauma). In both groups with inhalation injury, the patients were at risk of developing bacteremia: 13 of 23 of the immunoglobulin-treated patients and 12 of 16 patients of the control group. Bacteremic controls died at a lower score than bacteremic immunoglobulin-treated patients (8.6 vs. 10.3 points).(ABSTRACT TRUNCATED AT 250 WORDS)
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3.
A prospective trial of prophylactic intravenous immune globulin for the prevention of infections in severely burned patients
Waymack JP, Jenkins ME, Alexander JW, Warden GD, Miller AC, Carey M, Ogle CK, Kopcha RG
Burns. 1989;15((2):):71-6.
Abstract
A prospective randomized double-blind study evaluated the efficacy of i.v. immune globulin in preventing infectious complications in severely burned patients. Fifty patients were randomized to receive either i.v. immune globulin or placebo. Each group of patients was treated with twice weekly infusions for either 5 weeks or until the patients' wounds were covered. Patients treated with the immune globulin had an immediate correction of their depressed serum IgG levels, however there was no change in the infection or mortality rates. No adverse effects were noted with the immune globulin treatments. One potential weakness of this study was the greater burn surface area and a higher incidence of inhalation injury in adult patients treated with i.v. immune globulin compared to controls.
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4.
Effect of immunoglobulin G therapy on serum antibody titers to cytomegalovirus in burn patients
Moran KT, Thupari JN, O'Reilly TJ, Munster AM
American Journal of Surgery. 1988;155((2):):294-7.
Abstract
We attempted to determine the incidence and significance of cytomegalovirus infection and the effect of immunoglobulin G infusions on specific cytomegalovirus titers in burn patients. On admission, 48 percent of a group of 120 patients (mean burn size 28.5 percent of the total body surface area) were seronegative, including 95 percent of all patients under 20 years of age. Subsequently, 4 of a subgroup of 26 patients (15 percent) had development of a primary infection, and 1 of these patients died from overwhelming bacterial infection. Immunoglobulin G infusion used in the prophylaxis of the septic complications achieved high titers of cytomegalovirus-specific immunoglobulin G, as well as the subsets immunoglobulin G1 and immunoglobulin G3 which are also active against cytomegalovirus.
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5.
High dose intravenous immunoglobulin therapy in burn patients: pharmacokinetics and effects on microbial opsonization and phagocytosis
Hansbrough JF, Miller LM, Field TO Jr, Gadd MA
Pediatric Infectious Disease Journal. 1988;7((5 Suppl):):S49-56.
Abstract
Depressed serum immunoglobulin levels following severe burns may lead to subsequent infectious complications following such injuries. In a randomized study we administered multiple doses of Sandoglobulin (500 mg/kg) or albumin intravenously to patients with severe burn injuries and closely monitored serum IgG levels. Patients who received IgG therapy had earlier return of normal serum IgG levels compared to control patients; however, control patients attained normal IgG levels during the second postburn week. Serum half-lives of IgG following infusions were remarkably short (means, 47 hours for infusions within 3 days of injury and 154 hours for infusions in the third postburn week); Sandoglobulin has been reported to have approximately a 21-day half-life in normal individuals. We also measured the opsonic capacity of postburn serum, using fluorescein-labeled microbes and flow cytometry; we identified postburn opsonic defects with certain of the organisms as late as 15 days postinjury, even though serum IgG levels had normalized. These defects were corrected by the in vitro addition of Sandoglobulin to the incubation mixture.
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6.
Prophylactic intravenous immunoglobulin replacement in high-risk burn patients
Munster AM, Moran KT, Thupari J, Allo M, Winchurch RA
Journal of Burn Care & Rehabilitation. 1987;8((5):):376-80.
Abstract
Twenty patients with extensive thermal injury were entered into a prospective randomized double-blind trial of prophylactic intravenous immunoglobulin administration. Ten patients received intravenous immunoglobulin and ten, albumin controls. No statistically significant difference was found between mortality rates, mortality rates from sepsis, the incidence of positive blood cultures, the positive quantitative wound biopsies, urine cultures, or positive intravenous line cultures. No significant improvement was noted in assays of neutrophil chemotactic index or intracellular kill, assays of lymphocyte function, or helper/suppressor ratio. We did, however, note significant improvement in the incidence of polymicrobial blood cultures, cytomegalovirus titers, and blood endotoxin concentration in treated patients. While the high incidence of inhalation injury (16 out of 20 patients) and, therefore, the disproportionately high mortality rate (40% overall) in the study group do not permit extension of these observations to the burn patient population at large, certain cautious recommendations may be made with regard to the use of intravenous immunoglobulin G in the management of burn patients.