Veno-Venous Ecmo For Toxic Shock Syndrome In A Former Preterm Neonate

Introduction: Toxic shock syndrome (TSS) is an acute multisystemic toxin-mediated disease, characterized by high fever, hypotension and cutaneous rash followed by desquamation of the skin. TSS is thought to be a superantigen-mediated disease mainly caused by toxin-producing strains of Staphylocccus aureus (TSST-1) or Streptococcus pyogenes. We describe a case of TTS following inguinal hernia repair in a former preterm neonate with specific emphasis on the use of veno-venous ECMO as rescue treatment.

Case report: A few days after elective inguinal hernia repair, a former preterm neonate was readmitted in the NICU because of fever, diarrhoea and tenderness of the abdomen without signs of inflammation of the surgical site.

Within 24h after admission, respiratory support was initiated because of clinical deterioration with the full spectrum of sepsis necessitating additional fluid boluses and inotropics. The second day, a macular rash was observed. This rash in combination with the clinical spectrum was suggestive for TSS. TSST-1 toxin producing Staphyloccoccus aureus was isolated form the inguinal wound.

Besides vancomycin, clindamycin was initiated and a surgical cleaning of the wound was performed. Because of further clinical progression into ARDS, veno-venous ECMO was initiated and provided for about 100 hours. Extubation was possible 4 days after the ECMO run was terminated and the neonate was discharged from the hospital 12 days later.

Discussion: TTS syndrome has only rarely been reported in neonates and young infants.

We feel that 'take home messages' of this case are that:

• the presenting symptoms might suggest peritonitis, as already reported in literature

• local wound inflammation is modest, but surgical cleaning is mandatory to reduce the bacterial load

• as part of the supportive therapy, veno-venous ECMO should be considered when respiratory insufficiency is documented.