Intended for healthcare professionals

Practice Lesson of the week

New football boots and toxic shock syndrome

BMJ 2006; 332 doi: (Published 08 June 2006) Cite this as: BMJ 2006;332:1376
  1. C M Taylor (, consultant nephrologist1,
  2. F A I Riordan, consultant paediatrician2,
  3. C Graham, consultant microbiologist1
  1. 1 Birmingham Children's Hospital, Birmingham,
  2. 2 Heartlands Hospital, Birmingham
  1. Correspondence to: C M Taylor, Department of Nephrology, Birmingham Children's Hospital, Birmingham B4 6NH
  • Accepted 7 March 2006

Toxic shock syndrome is unusual in childhood. Although it is easily recognised by those who have seen it before—and is an important diagnosis to make—few clinicians will have encountered a case. We present two similar cases. Both patients developed friction blisters over the area of calcaneal insertion of their Achilles tendons—the result of wearing new football boots. The blisters contained Staphylococcus aureus, which in one case was found to express the toxic shock syndrome gene TSS1. Both had a secondary rash during recovery.

Case reports

Case 1

A 13 year old girl played a competitive game of football in new boots and developed friction blisters over both heels. The next day she developed fever, lethargy, and vomiting but remained alert and oriented. Within a few hours, she had developed an erythematous, macular, coalescent rash over the trunk, back, and all limbs (figure). Twenty four hours later she developed diarrhoea, which lasted a few hours, and abdominal pain.

Case 1: Erythematous rash on patient's arm and trunk

She was admitted to her local hospital, where the rash was recorded as having spread to the hands and feet, with oedema of the fingers. The buccal and labial mucosae were erythematous and the conjunctivae injected. On arrival at hospital her blood pressure was 106/46 mm Hg. She had no anaemia, lymphadenopathy, or hepatosplenomegaly and no abnormalities in the respiratory or central nervous systems. Her last menstrual period had been 10 days previously and she never used vaginal tampons.

She was treated empirically with intravenous ceftriaxone 3.2 g daily (she weighed 64 kg). A blood culture taken before she started taking antibiotics proved sterile. Over the …

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