Pediatric emergency medicine trisk 591

e-TABLE 94.1
CASE DEFINITIONS FOR STAPHYLOCOCCAL AND
STREPTOCOCCAL TOXIC SHOCK SYNDROME a


Clinical criteria

Laboratory criteria

Staphylococcal Fever ≥102.2°F (≥38.9°C)
b

Streptococcal c

Blood or CSF cultures
positive for S. aureus
and
Rash: diffuse macular erythroderma Negative serologies for
other pathogens that
Desquamation: 1–2 wks after rash
can mimic TSS:
onset
RMSF, leptospirosis,
measles
Hypotension
Multisystem involvement:
• GI: vomiting or diarrhea at onset
of illness
• Muscular: myalgias or CK at least
2ì ULN
ã Mucous membrane: hyperemia of

conjunctival, oropharynx, or
vagina
ã Renal: BUN or creatinine at least
2ì ULN or pyuria
ã Hepatic: total bilirubin, ALT, or
AST at least 2ì ULN
ã Hematologic: platelets
<100,000/mm3
ã CNS: disorientation or alteration
in consciousness without focal
neurologic signs in the absence
of fever or hypotension
Hypotension
Isolation of GAS
Multisystem involvement (≥2)
• ARDS: diffuse pulmonary
infiltrates and hypoxemia in the
absence of CHF; generalized
edema; or pleural or peritoneal
effusion with hypoalbuminemia


• Rash: generalized erythematous
macular; may desquamate
• Soft tissue necrosis (necrotizing
fasciitis or myositis, or
gangrene)
ã Renal: BUN or creatinine at least
2ì ULN or pyuria
ã Hepatic: total bilirubin, ALT, or

AST at least 2ì ULN
• Coagulopathy: platelets
<100,000/mm3 or DIC
a Centers

for Disease Control and Prevention Case Definitions, 2010 (Streptococcal) and 2011
(Staphylococcal). Available online at />CondYrID=869&DatePub=1/1/2011 %2012:00:00%20AM. Accessed February 26, 2019.
b Probable cases meet the laboratory criteria and 4/5 clinical criteria; confirmed cases meet the laboratory
criteria and 5/5 clinical criteria.
c Probable cases met the clinical case definition in the absence of another etiology and have GAS isolated
from a nonsterile site; confirmed cases meet the laboratory criteria and have GAS isolated from a sterile
site.
GI, gastrointestinal; CK, creatinine kinase; ULN, upper limit of normal; BUN, blood urea nitrogen; ALT,
alanine aminotransferase; AST, aspartate aminotransferase; CSF, cerebrospinal fluid; TSS, toxic shock
syndrome; RMSF, Rocky Mountain spotted fever; CHF, congestive heart failure; DIC, disseminated
intravascular coagulation; GAS, group A streptococcus.


e-TABLE 94.2
CAUSES OF ENCEPHALITIS AND MENINGOENCEPHALITIS IN
IMMUNOCOMPETENT CHILDREN
Viral

Bacterial

Fungal
Protozoal

Helminthic

Relatively more common: enterovirus, HSV, EBV, West Nile,
St. Louis, tick-borne encephalitis virus, VZV, equine
encephalitides (Eastern, Western, Venezuelan), La Crosse,
influenza
Less common: LCMV, Japanese encephalitis virus, measles,
mumps, rabies
Relatively more common: Mycobacterium tuberculosis,
Bartonella, Ehrlichia, Rickettsia rickettsii (Rocky Mountain
spotted fever)
Less common: Borrelia burgdorferi (Lyme disease), Coxiella
burnetti (Q fever), Treponema pallidum (syphilis)
Often identified, but most evidence anecdotal: Mycoplasma
pneumoniae
Histoplasma, Blastomyces, Coccidioides
Naegleria fowleri (primary amebic meningoencephalitis),
Balamuthia mandrillaris and Acanthamoeba (both causes of
granulomatous amebic encephalitis), Toxoplasma gondii
Baylisascaris (raccoon roundworm, endemic in US.),
Gnathostoma (nematode of fish, reptiles, and amphibians
most common in Southeast Asia and Latin America),
Angiostrongylus (rat lungworm, a cause of eosinophilic
meningitis in Southeast Asia)

HSV, herpes simplex virus; EBV, Epstein–Barr virus; VZV, varicella zoster virus; LCMV, lymphocytic
choriomeningitis virus.