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Streptococcal Toxic Shock Syndrome (STSS): An Overview

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by Dr B.J.C.Perera
MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK),
FRCP(Edin), FRCP(Lond), FRCPCH(UK), FSLCPaed, FCCP, Hony. FRCPCH(UK), Hony. FCGP(SL)
Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine,
University of Colombo, Sri Lanka.
Joint Editor, Sri Lanka Journal of Child Health
Section Editor, Ceylon Medical Journal

There is a significant discussion besides a marked apprehension and anxiety on the subject of Streptococcal Toxic Shock Syndrome (STSS) at present, particularly because of the apparent spread of this disease somewhat widely in Japan. Streptococcal Toxic Shock Syndrome (STSS) is not a new disease and has been known for a considerable length of time. The specific term “Streptococcal Toxic Shock Syndrome” began to gain recognition around the early to mid-1980s as cases were identified and studied more closely by clinicians and researchers.

It is an extremely severe illness caused by infection with certain strains of a bug referred to as Lancefield Group A Streptococcus (GAS), scientifically known as Streptococcus pyogenes. Group A is the most notable group of this entire family of microbes associated with a variety of human infections, ranging from mild throat infections to life-threatening conditions like STSS and intensive tissue destruction known as necrotising fasciitis. STSS is characterized by a rapid onset of low blood pressure, shock, and failure of multiple organs, often leading to significant morbidity and mortality. Understanding the causation, clinical presentation, treatment strategies, and prognosis of STSS is crucial for healthcare providers to manage and mitigate the impact of this life-threatening syndrome effectively.

STSS is a rare but major illness that could affect individuals of all ages but it tends to have a higher incidence in adults and the elderly. Factors that increase the risk include chronic illnesses such as diabetes, cancer, and heart disease, as well as the use of certain medications like nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen, and diclofenac.

The disease is caused by the entry of the causative bug into a normally sterile site, such as the bloodstream or deep tissues. The bacteria produce poisons that act as superantigens, which bypass normal antigen processing and directly stimulate a massive release of chemically active substances called cytokines. This cytokine storm leads to widespread cell damage, leaking of fluid from blood vessels called capillary leakage, a drastic drop in blood pressure leading to shock, and multi-organ failure.

Early signs include fever, chills, malaise, myalgia, nausea, vomiting, and diarrhoea. Rapid progression to shock occurs in some cases with very low blood pressure, increased heart rate, and heavy rapid breathing. Patients may develop a diffuse reddish rash on the skin which shows peeling, particularly on the palms and soles. With further progression of the clinical features multi-organ dysfunction, including kidney and liver failure, acute respiratory distress syndrome (ARDS), bleeding tendencies and altered mental status would occur.

The diagnosis of STSS is based on clinical criteria, as outlined by the Centers for Disease Control and Prevention (CDC) in Atlanta USA, and include low blood pressure and at least two of several multiple organ involvement such as of kidneys, blood clotting disturbances, liver involvement, lung involvement and soft-tissue destruction, including necrotic destruction of fascia and muscles.

The treatment of STSS requires prompt and aggressive intervention to manage blood pressure drop and shock, eradicate the infection, and support failing organs. Fluid balance and immediate correction of fluid deficits, blood pressure augmentation using specific medications, intensive antibiotic therapy using drugs that are known to specifically attack the causative microbe, intravenous immunoglobulin, and surgical care for those patients with tissue destruction. Many with complications would need intensive care with specific organ supportive care like ventilation for respiratory inadequacy and dialysis for supporting the kidneys. Intensive monitoring of many potential metabolic changes, bleeding disorders and salt balance corrections is mandatory.

STSS is associated with high mortality rates, ranging from 30% to 70%, depending on the rapidity of diagnosis and appropriate interventions. Factors contributing to poor prognosis include delayed diagnosis and treatment, older age, and presence of other comorbidities such as diabetes, and severity of the blood pressure drop as well as the presence of multi-organ failure at presentation.

Survivors of STSS may experience long-term sequelae, including chronic kidney functional disturbance, respiratory issues secondary to ARDS, psychological impacts such as post-traumatic stress disorder (PTSD) and depression, as well as physical disabilities resulting from amputations or severe soft-tissue damage.

Preventive strategies focus on early recognition and treatment of Group A Streptococcal (GAS) infections to prevent progression to invasive disease with proper wound care and hygiene, timely treatment of streptococcal pharyngitis with appropriate antibiotics and awareness as well as education about the signs and symptoms of severe GAS infections.

Streptococcal Toxic Shock Syndrome (STSS) is a medical emergency characterized by rapid onset of shock and multi-organ failure, necessitating immediate and aggressive treatment. Understanding the virulence mechanisms of GAS, the clinical manifestations of STSS, and the appropriate and early management targeted at the causative microbe, are vital initiatives for healthcare professionals. Despite advances in medical care, the high mortality rate associated with STSS underscores the importance of early recognition, prompt intervention, and supportive care, in improving patient outcomes. Continued research and education are essential to further enhance our understanding and management of this life-threatening condition.

Although the disease has not reached Sri Lanka in any significant proportion as yet, there is no time at all for complacency. It is well and good as well as most appropriate for the authorities to reassure the general public against undue anxiety but together with that, proper information regarding the disease too should be provided to the general public through all available media channels. Intense monitoring of people arriving through airports and seaports is mandatory as transcontinental travel is quite common these days. One has to keep in mind that the disease can escalate very rapidly over 24 to 48 hours and people who arrive through the ports of entry into the country may only have the earliest symptoms of the disease such as fever and general body aches at the time of arrival, only to have the situation develop very rapidly into a life-threatening illness within a very short time after arrival. Therefore, vigilance of the highest order is the very urgent need of the hour.



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Crucial test for religious and ethnic harmony in Bangladesh

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A political protest that led to governmental change in Bangladesh mid last year. (photograph: imago)

Will the Bangladesh parliamentary election bring into being a government that will ensure ethnic and religious harmony in the country? This is the poser on the lips of peace-loving sections in Bangladesh and a principal concern of those outside who mean the country well.

The apprehensions are mainly on the part of religious and ethnic minorities. The parliamentary poll of February 12th is expected to bring into existence a government headed by the Bangladesh Nationalist Party (BNP) and the Islamist oriented Jamaat-e-Islami party and this is where the rub is. If these parties win, will it be a case of Bangladesh sliding in the direction of a theocracy or a state where majoritarian chauvinism thrives?

Chief of the Jamaat, Shafiqur Rahman, who was interviewed by sections of the international media recently said that there is no need for minority groups in Bangladesh to have the above fears. He assured, essentially, that the state that will come into being will be equable and inclusive. May it be so, is likely to be the wish of those who cherish a tension-free Bangladesh.

The party that could have posed a challenge to the above parties, the Awami League Party of former Prime Minister Hasina Wased, is out of the running on account of a suspension that was imposed on it by the authorities and the mentioned majoritarian-oriented parties are expected to have it easy at the polls.

A positive that has emerged against the backdrop of the poll is that most ordinary people in Bangladesh, be they Muslim or Hindu, are for communal and religious harmony and it is hoped that this sentiment will strongly prevail, going ahead. Interestingly, most of them were of the view, when interviewed, that it was the politicians who sowed the seeds of discord in the country and this viewpoint is widely shared by publics all over the region in respect of the politicians of their countries.

Some sections of the Jamaat party were of the view that matters with regard to the orientation of governance are best left to the incoming parliament to decide on but such opinions will be cold comfort for minority groups. If the parliamentary majority comes to consist of hard line Islamists, for instance, there is nothing to prevent the country from going in for theocratic governance. Consequently, minority group fears over their safety and protection cannot be prevented from spreading.

Therefore, we come back to the question of just and fair governance and whether Bangladesh’s future rulers could ensure these essential conditions of democratic rule. The latter, it is hoped, will be sufficiently perceptive to ascertain that a Bangladesh rife with religious and ethnic tensions, and therefore unstable, would not be in the interests of Bangladesh and those of the region’s countries.

Unfortunately, politicians region-wide fall for the lure of ethnic, religious and linguistic chauvinism. This happens even in the case of politicians who claim to be democratic in orientation. This fate even befell Bangladesh’s Awami League Party, which claims to be democratic and socialist in general outlook.

We have it on the authority of Taslima Nasrin in her ground-breaking novel, ‘Lajja’, that the Awami Party was not of any substantial help to Bangladesh’s Hindus, for example, when violence was unleashed on them by sections of the majority community. In fact some elements in the Awami Party were found to be siding with the Hindus’ murderous persecutors. Such are the temptations of hard line majoritarianism.

In Sri Lanka’s past numerous have been the occasions when even self-professed Leftists and their parties have conveniently fallen in line with Southern nationalist groups with self-interest in mind. The present NPP government in Sri Lanka has been waxing lyrical about fostering national reconciliation and harmony but it is yet to prove its worthiness on this score in practice. The NPP government remains untested material.

As a first step towards national reconciliation it is hoped that Sri Lanka’s present rulers would learn the Tamil language and address the people of the North and East of the country in Tamil and not Sinhala, which most Tamil-speaking people do not understand. We earnestly await official language reforms which afford to Tamil the dignity it deserves.

An acid test awaits Bangladesh as well on the nation-building front. Not only must all forms of chauvinism be shunned by the incoming rulers but a secular, truly democratic Bangladesh awaits being licked into shape. All identity barriers among people need to be abolished and it is this process that is referred to as nation-building.

On the foreign policy frontier, a task of foremost importance for Bangladesh is the need to build bridges of amity with India. If pragmatism is to rule the roost in foreign policy formulation, Bangladesh would place priority to the overcoming of this challenge. The repatriation to Bangladesh of ex-Prime Minister Hasina could emerge as a steep hurdle to bilateral accord but sagacious diplomacy must be used by Bangladesh to get over the problem.

A reply to N.A. de S. Amaratunga

A response has been penned by N.A. de S. Amaratunga (please see p5 of ‘The Island’ of February 6th) to a previous column by me on ‘ India shaping-up as a Swing State’, published in this newspaper on January 29th , but I remain firmly convinced that India remains a foremost democracy and a Swing State in the making.

If the countries of South Asia are to effectively manage ‘murderous terrorism’, particularly of the separatist kind, then they would do well to adopt to the best of their ability a system of government that provides for power decentralization from the centre to the provinces or periphery, as the case may be. This system has stood India in good stead and ought to prove effective in all other states that have fears of disintegration.

Moreover, power decentralization ensures that all communities within a country enjoy some self-governing rights within an overall unitary governance framework. Such power-sharing is a hallmark of democratic governance.

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Celebrating Valentine’s Day …

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Valentine’s Day is all about celebrating love, romance, and affection, and this is how some of our well-known personalities plan to celebrate Valentine’s Day – 14th February:

Merlina Fernando (Singer)

Yes, it’s a special day for lovers all over the world and it’s even more special to me because 14th February is the birthday of my husband Suresh, who’s the lead guitarist of my band Mission.

We have planned to celebrate Valentine’s Day and his Birthday together and it will be a wonderful night as always.

We will be having our fans and close friends, on that night, with their loved ones at Highso – City Max hotel Dubai, from 9.00 pm onwards.

Lorensz Francke (Elvis Tribute Artiste)

On Valentine’s Day I will be performing a live concert at a Wealthy Senior Home for Men and Women, and their families will be attending, as well.

I will be performing live with romantic, iconic love songs and my song list would include ‘Can’t Help falling in Love’, ‘Love Me Tender’, ‘Burning Love’, ‘Are You Lonesome Tonight’, ‘The Wonder of You’ and ‘’It’s Now or Never’ to name a few.

To make Valentine’s Day extra special I will give the Home folks red satin scarfs.

Emma Shanaya (Singer)

I plan on spending the day of love with my girls, especially my best friend. I don’t have a romantic Valentine this year but I am thrilled to spend it with the girl that loves me through and through. I’ll be in Colombo and look forward to go to a cute cafe and spend some quality time with my childhood best friend Zulha.

JAYASRI

Emma-and-Maneeka

This Valentine’s Day the band JAYASRI we will be really busy; in the morning we will be landing in Sri Lanka, after our Oman Tour; then in the afternoon we are invited as Chief Guests at our Maris Stella College Sports Meet, Negombo, and late night we will be with LineOne band live in Karandeniya Open Air Down South. Everywhere we will be sharing LOVE with the mass crowds.

Kay Jay (Singer)

I will stay at home and cook a lovely meal for lunch, watch some movies, together with Sanjaya, and, maybe we go out for dinner and have a lovely time. Come to think of it, every day is Valentine’s Day for me with Sanjaya Alles.

Maneka Liyanage (Beauty Tips)

On this special day, I celebrate love by spending meaningful time with the people I cherish. I prepare food with love and share meals together, because food made with love brings hearts closer. I enjoy my leisure time with them — talking, laughing, sharing stories, understanding each other, and creating beautiful memories. My wish for this Valentine’s Day is a world without fighting — a world where we love one another like our own beloved, where we do not hurt others, even through a single word or action. Let us choose kindness, patience, and understanding in everything we do.

Janaka Palapathwala (Singer)

Janaka

Valentine’s Day should not be the only day we speak about love.

From the moment we are born into this world, we seek love, first through the very drop of our mother’s milk, then through the boundless care of our Mother and Father, and the embrace of family.

Love is everywhere. All living beings, even plants, respond in affection when they are loved.

As we grow, we learn to love, and to be loved. One day, that love inspires us to build a new family of our own.

Love has no beginning and no end. It flows through every stage of life, timeless, endless, and eternal.

Natasha Rathnayake (Singer)

We don’t have any special plans for Valentine’s Day. When you’ve been in love with the same person for over 25 years, you realise that love isn’t a performance reserved for one calendar date. My husband and I have never been big on public displays, or grand gestures, on 14th February. Our love is expressed quietly and consistently, in ordinary, uncelebrated moments.

With time, you learn that love isn’t about proving anything to the world or buying into a commercialised idea of romance—flowers that wilt, sweets that spike blood sugar, and gifts that impress briefly but add little real value. In today’s society, marketing often pushes the idea that love is proven by how much money you spend, and that buying things is treated as a sign of commitment.

Real love doesn’t need reminders or price tags. It lives in showing up every day, choosing each other on unromantic days, and nurturing the relationship intentionally and without an audience.

This isn’t a judgment on those who enjoy celebrating Valentine’s Day. It’s simply a personal choice.

Melloney Dassanayake (Miss Universe Sri Lanka 2024)

I truly believe it’s beautiful to have a day specially dedicated to love. But, for me, Valentine’s Day goes far beyond romantic love alone. It celebrates every form of love we hold close to our hearts: the love for family, friends, and that one special person who makes life brighter. While 14th February gives us a moment to pause and celebrate, I always remind myself that love should never be limited to just one day. Every single day should feel like Valentine’s Day – constant reminder to the people we love that they are never alone, that they are valued, and that they matter.

I’m incredibly blessed because, for me, every day feels like Valentine’s Day. My special person makes sure of that through the smallest gestures, the quiet moments, and the simple reminders that love lives in the details. He shows me that it’s the little things that count, and that love doesn’t need grand stages to feel extraordinary. This Valentine’s Day, perfection would be something intimate and meaningful: a cozy picnic in our home garden, surrounded by nature, laughter, and warmth, followed by an abstract drawing session where we let our creativity flow freely. To me, that’s what love is – simple, soulful, expressive, and deeply personal. When love is real, every ordinary moment becomes magical.

Noshin De Silva (Actress)

Valentine’s Day is one of my favourite holidays! I love the décor, the hearts everywhere, the pinks and reds, heart-shaped chocolates, and roses all around. But honestly, I believe every day can be Valentine’s Day.

It doesn’t have to be just about romantic love. It’s a chance to celebrate love in all its forms with friends, family, or even by taking a little time for yourself.

Whether you’re spending the day with someone special or enjoying your own company, it’s a reminder to appreciate meaningful connections, show kindness, and lead with love every day.

And yes, I’m fully on theme this year with heart nail art and heart mehendi design!

Wishing everyone a very happy Valentine’s Day, but, remember, love yourself first, and don’t forget to treat yourself.

Sending my love to all of you.

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Banana and Aloe Vera

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To create a powerful, natural, and hydrating beauty mask that soothes inflammation, fights acne, and boosts skin radiance, mix a mashed banana with fresh aloe vera gel.

This nutrient-rich blend acts as an antioxidant-packed anti-ageing treatment that also doubles as a nourishing, shiny hair mask.

Face Masks for Glowing Skin:

Mix 01 ripe banana with 01 tablespoon of fresh aloe vera gel and apply this mixture to the face. Massage for a few minutes, leave for 15-20 minutes, and then rinse off for a glowing complexion.

*  Acne and Soothing Mask:

Mix 01 tablespoon of fresh aloe vera gel with 1/2 a mashed banana and 01 teaspoon of honey. Apply this mixture to clean skin to calm inflammation, reduce redness, and hydrate dry, sensitive skin. Leave for 15-20 minutes, and rinse with warm water.

Hair Treatment for Shine:

Mix 01 fresh ripe banana with 03 tablespoons of fresh aloe vera gel and 01 teaspoon of honey. Apply from scalp to ends, massage for 10-15 minutes and then let it dry for maximum absorption. Rinse thoroughly with cool water for soft, shiny, and frizz-free hair.

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