oa Veno-venous extracorporeal membrane oxygenation in a child with streptococcal toxic shock syndrome

Background: Streptococcal toxic shock syndrome (STSS) is a life-threatening illness associated with invasive or non-invasive group A streptococcal (GAS) infection with rapid progression and a high mortality rate.¹ There are limited data on the use of extracorporeal membrane oxygenation (ECMO) in toxic shock syndrome (TSS) with few case reports in adults with TSS-induced cardiac dysfunction^2,3 and a pediatric series of severe group A streptococcal infections from Australia.¹ The mode of ECMO was veno-arterial (VA) in all these case reports due to significant myocardial failure. According to our knowledge, we present the first reported case of STSS in a child managed with veno-venous (VV) ECMO. Methods: Clinical presentation, investigations, management, and outcome of the child was followed from the health records. The study was exempt from ethical approval. Detailed search of the published medical articles did not reveal similar publication. Results: A 13-month-old, previously healthy child presented in a state of shock 3 days after sustaining a burn wound to the dorsum of the left hand. Blood and wound cultures were positive for Streptococcus pyogenes, and there were signs of multiorgan failure, satisfying the Center for Disease Control (CDC) criteria for STSS. Acute respiratory distress syndrome (ARDS) developed on day 2 of presentation, accompanied by hemodynamic instability requiring support with multiple inotropes with a modified inotropic score of 117.5. Echocardiography revealed a structurally normal heart with ejection fraction of 40%. Hemodynamics were found to be associated with blood oxygen saturation. Blood pressure increased on increasing SpO2 with no change in the inotropic support. VV ECMO was initiated when the oxygenation index reached 68 in spite of being on inotropes. Inotropic support was weaned and stopped after 12 h. The child remained on ECMO for 7 days before being successfully decannulated. Conclusions: As the underlying cause of STSS is frequently treatable, ECMO may be considered early in the management of these cases when conservative measures fail. Presence of inotropic support should not be considered as a contraindication for VV ECMO in pediatric STSS.^4,5