This case involves an 8-year-old female who initially presented to her pediatrician after injuring her knee on the school playground. The patient experienced persistent pain and intermittent fevers following the injury, and she was sent for imaging and blood work. Her white blood cell count was noted to be very elevated. After reviewing the labs, the pediatrician prescribed aspirin for pain management. A week later, the patient was brought in with complaints of a swollen neck and a knot in her jaw. She was diagnosed with acute parotitis and prescribed antibiotics. Within 2 days of beginning the antibiotic regiment, the child suffered from high fever, altered mental status, and trouble breathing. She was taken to the emergency room and became unresponsive upon arrival. The patient was emergently intubated but expired within minutes. An autopsy determined the cause of death to be toxic shock syndrome and sepsis.
Question(s) For Expert Witness
- 1. Do you routinely evaluate pediatric patients similar to the one described?
- 2. What are the most common causes of parotitis in this population?
- 3. How common is toxic shock syndrome in this population?
Expert Witness Response E-042480
I am a pediatric infectious disease specialist who is routinely called upon to consult on cases of sepsis, TSS, parotitis, disease due to staph aureus, or any combination of those (along with all the other areas of pediatric ID). The most common cause of bacterial parotitis in this population is S.aureus, far and away outnumbering others, though other oral bacteria like various streptococci and oral anaerobes can be a cause. Bactrim is, according to most guidelines I have seen, not considered a first-line drug for parotitis. While it may cover S.aureus, it has too many other holes in its coverage. S. aureus toxic shock syndrome is rare, with recent studies pegging the incidence at less than one case per 100,000 annually. This is a very unfortunate case–while S.aureus can be fatal, it is extremely rare to see death from it in an otherwise healthy child. More specifically, my area of interest and expertise is in bacterial infections and antibiotic use. I am the medical director for our hospital’s antibiotic stewardship program and I serve on a number of state and national committees dedicated to promoting appropriate antibiotic use and combatting inappropriate antibiotic use.
Expert Witness Response E-018646
I am a pediatric infectious diseases specialist with 10+ years of experience in pediatric infectious diseases. There is a high suspicion for septic arthritis of the knee in an 8-year-old patient with knee pain, fever, and increased WBC with a left shift. The etiology for septic arthritis in this age group would be S. aureus as a #1 cause. Treatment for knee pain in am 8-year-old female would not include aspirin therapy. In pediatrics, aspirin is not used due to the increased risk for Reye’s syndrome. Parotitis in an 8-year-old that is unilateral and painful, especially with fever, would be concerning for a bacterial etiology, or due to underlying illness. MRSA is the most common bacterial etiology. Other factors to consider include a preceding illness, HIV, TB, vaccination status, and family history/autoimmune syndrome. I have published on a case of MRSA that progressed to acute osteomyelitis. Toxic shock syndrome is an uncommon disease. However, in the setting of a recent acute illness suspicious for septic arthritis, the likelihood of TSS is increased.