A 12-year-old boy was admitted to the emergency room with fever, hypotension, tonsillar hyperemia, petechiae on palate, diarrhea, and rash. Laboratory data: hemoglobin 119 g/L; leucocytes 7.8 × 109/L (70% band neutrophils, 27% eosinophils); creatinine 119 µmol/L; alanine aminotransferase 1.97µkat/L; aspartate aminotransferase 1.37µkat/L; lactate dehydrogenase 4.82µkat/L; troponin T 106 ng/L; NT-proBNP 645.6 pmol/L; c-reactive protein 1323 nmol/L; procalcitonin 249 ng/L. Staphylococcus aureus was later identified in blood culture. A diagnosis of staphylococcal toxic shock syndrome was made.

The peripheral blood films showed (Fig. 1): neutrophils with phagocytosed cocci, Döhle bodies in neutrophils and eosinophils (day 1); eosinophils with three or more lobules, vacuolated (day 1–3) and with blue granules (day 3); lymphoplasmocytes (day 3); macropolycytes and neutrophils with six lobules (day 6).

Fig. 1
figure 1

Peripheral blood film findings on the first (admission), third and sixth day

Full size image

During convalescence, he exhibited axillar and inguinal desquamation.

Toxic Shock Syndrome (TSS) is a severe acute disease characterized by high fever, hypotension, rash, multiple organ dysfunction and desquamation during convalescence [1,2,3]. Multiple organ dysfunction can be present in 8–12 h, and desquamation occurs 10–21 days after disease onset [2]. TSS is caused by toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes [1, 3]. TSS can develop if toxins are produced, and no protective host antibodies are present. Children and young adults are more susceptible to TSS [3].

In < 5% of cases of staphylococcal TSS, blood cultures are positive [2]. TSS remains a rare but severe disease [1].

The early diagnosis of TSS is important because specific antitoxin and immunoglobulin treatments must be started soon and to adjust antimicrobial treatment to reduce exotoxin synthesis [1, 2].

The peripheral blood film can play an important role in the early diagnosis of TSS.