65 Severe Soft Tissue Infection with Group a Streptococcus (GAS) in Children

To describe the demography, clinical features, risk factors and epidemiology of severe soft tissue infection with GAS in children. Retrospective chart review of cases of severe soft tissue infections admitted at a tertiary care pediatric hospital between 1/1/1993 and 30/7/2003. Cases were included if GAS was isolated in blood culture or local site and they were diagnosed with necrotizing fasciitis (NF), myositis, severe cellulitis or abcesses by surgery, pathology, radiology and/or high clinical suspicion. Children with immunosuppression or neoplasia were excluded. Among 32 identified cases, 43.8 % were male, 34.4% were not caucasian and 78.1% were previously healthy. Distribution in time is shown in figure 1. Median age was 4.5 years (range, 2 month to 15.2 years). Forty-one per cent (13/32) had NF, 43.8% (14/32) abcesses, 12.5% (4/32) severe cellulitis and 3.1% (1/32) myositis. More than one site was infected in 6 cases. Varicella was present in 68.8% of cases. Eight fulfilled criteria of streptococcal toxic shock syndrome (STSS); 7 of them had NF. Nine were admitted in PICU. Number of cases of severe GAS infection per year. On admission, median temperature was 39.2°C, median leukocytes count was 16.0×109/L with a median of 77% of neutrophils. Creatinine kinase level (CK) was abnormal in 30.8% (4/13) of the NF cases. Only 12.5% were bacteremic. Twenty-one cases were surgically debrided. Median time of surgery from onset of local signs was 3 days (range, 1 to 11). Six cases required more than one surgery. One patient had an amputation. Among 13 cases of NF, 9 were confirmed by biopsy. Three of these had no sign of necrosis during surgery. Complications, reported in 25% of cases (7/28), included bone avascular necrosis, deforming scar, limb amputation, stroke, intracerebral abscess, hemiparesis, optic atrophy, palpebral ptosis and arthrosis. One patient (3.1%) with NF and varicella died on the day of admission. Two peaks (1998 and 2003) of severe soft tissue GAS infection were observed during the study period. NF is difficult to diagnose because of unspecific clinical features and unhelpful laboratory tests, such as CK. High index of suspicion is needed, particularly when varicella or STSS are present. To prove the diagnosis, a biopsy can be helpful when there is no necrosis seen during surgery. Further epidemiological studies are warranted to explain peaks of disease. Activity of varicella virus or GAS in the community could be related. Varicella vaccine could decrease the incidence of the disease.

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