Streptococcal fasciitis with toxic shock syndrome in the pediatric patient

Necrotizing fasciitis (NF) is a distinctive soft tissue infection usually caused by Group A beta-hemolytic streptococcus, often seen in association with varicella in the previously healthy child. Its fulminant course is associated with great morbidity and high case-fatality rates, especially when it occurs in conjunction with streptococcal toxic shock syndrome. It differs from simple cellulitis in clinical presentation, appearance on examination, and need for urgent surgical intervention. The patient is irritable and complains of severe pain in the involved site, which is usually the extremity. On examination, exquisite pain on palpation of the involved site is confirmed, which is out of proportion to the cutaneous findings. Shock, multiorgran failure, and death will ensue if the diagnosis is not promptly recognized. The five keys to management include fluid management, aggressive debridement of necrotic tissues, anticipation and management of multisystem organ failure, appropriate parenteral antimicrobial therapy using penicillin and clindamycin, and use of intravenous immunoglobulin (IVIG).