Assessing the impact of intravenous immunoglobulin in the management of streptococcal toxic shock syndrome: a noble but difficult quest.

The annual incidence of invasive group A streptococcal disease in the developed world has been stable for at least 2 decades at 2.0–4.0 cases per 100,000 persons per year [1–3]. Streptococcal toxic shock syndrome (TSS) and necrotizing fasciitis are among the most severe manifestations of invasive group A streptococcal infection, with case-fatality rates of 30%-70% in adult patients with streptococcal TSS [2, 4–6]. Fortunately, these syndromes and their severe complications are rare in pediatric populations. In a recent study of 10 sites in the United States, covering a population of 29.7 million persons, 572 patients aged !10 years had invasive group A streptococcal infection [2]. Of these, only 5 (0.9%) developed necrotizing fasciitis and only 26 (4.6%) developed streptococcal TSS, and the case-fatality rate in patients with streptococcal TSS was 7.2%. Only 2 prior publications have attempted to assess the efficacy of intrave-