As the World Cup kicks off, doctors in this week's British Medical Journal report an unusual condition that can develop in budding young footballers.
They describe two cases of toxic shock syndrome (TSS) in children after playing football in new boots. Both developed friction blisters over their Achilles tendons. The blisters contained Staphylococcus aureus, which in one case was found to express the toxic shock syndrome gene (TSS1).
In the first case, a 13-year-old girl developed friction blisters over both heels after playing a competitive game of football in new boots. She was admitted to her local hospital after developing a range of symptoms including fever, rash, abnormally low blood pressure (hypotension), vomiting and diarrhoea.
Further examination revealed a blister, 2cm in diameter, over each of her Achilles tendons containing the bacterium Staphylococcus aureus with the toxic shock syndrome gene (TSS1). A diagnosis of toxic shock syndrome was made and she was treated with antibiotics.
In the second case, a healthy 11-year-old boy played football in a new pair of boots, causing a blister on his right heel. Over the next two days he developed fever, vomiting and diarrhoea, and a rash.
Within hours of admission to hospital, his condition deteriorated and his blood pressure fell. Again, pus from the blister on his heel contained Staphylococcus aureus. He also developed a secondary rash during convalescence.
Toxic shock syndrome has become less common since the link with tampon use was recognised in the 1980s, write the authors. And in children, for whom this association does not apply, the syndrome is rare. But these cases show that the syndrome may follow relatively trivial skin trauma.
They suggest that doctors consider toxic shock syndrome in a child with rash, fever and hypotension. They also stress the need to search carefully for the primary infection, as it may not be immediately obvious, and to be aware that secondary rashes occur.