Therapeutic plasma exchange in pediatric streptococcal toxic shock syndrome with severe digital ischemia

Streptococcal toxic shock syndrome (STSS) is a fulminant, toxin-mediated condition associated with multiorgan failure and high mortality in children. Thrombocytopenia-associated multiple organ failure (TAMOF) represents a severe sepsis-related thrombotic microangiopathy characterized by thrombocytopenia, microcirculatory dysfunction, and mortality exceeding 50%.

We report a 2.5-year-old boy with group A β-hemolytic Streptococcus infection who rapidly progressed to catecholamine-resistant septic shock, respiratory failure, and acute kidney injury requiring continuous venovenous hemodiafiltration. His course was complicated by worsening thrombocytopenia and severe microcirculatory impairment consistent with evolving TAMOF. Despite hemodynamic stabilization with vasoactive agents, hydrocortisone, and milrinone, progressive digital ischemia developed. Therapeutic plasma exchange (TPE) was initiated as one component of multimodal therapy. Peripheral perfusion subsequently stabilized during ongoing multimodal therapy, and amputation was avoided. The patient recovered without functional sequelae.

This case highlights pediatric STSS complicated by suspected TAMOF and severe digital ischemia managed with multimodal supportive care including TPE. Given concurrent interventions, no causal attribution to any single therapy is possible. Early recognition of TAMOF-associated complications and timely escalation of organ support remain the central priorities in such cases.