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Background A subcategory of severe septic shock, toxic shock syndrome (TSS) represents up to 20% of pediatric septic shock in the United States. Diagnostic criteria for streptococcal TSS (STSS) and non-streptococcal TSS (NSTSS) were first published by the CDC in the early 1990s, with updates, respectively, in 2010 and 2011. Methods The Nationwide Children’s Hospital electronic medical record was queried for inpatient hospitalizations with ICD-9/10 codes of interest between 1/1/2010 and 8/31/2017. The query returned 579 hospitalizations which were assessed for adherence to STSS and NSTSS criteria published by the CDC. 61 cases of TSS were identified: 27 STSS, 32 NSTSS. The prevalence of organ system involvement was quantified, and organ system involvement unanticipated by CDC criteria was examined for prevalence, quality and chronology. Results TSS patients were predominately female (62%) with an average age of 12. The most common presentation of TSS was with hypotension (93%), fever (82%) and rash (72%). Findings unanticipated by CDC criteria include: pyuria in STSS (41%), pulmonary involvement in NSTSS (66%) and coagulation abnormalities in NSTSS (92%). Pyuria in STSS was commonly accompanied by protein (73%) and leukocyte esterase (55%) on urinalysis. Pyuria also commonly presented with hematuria (45%). Radiographic evidence of pulmonary involvement in NSTSS was typically described as bilateral/diffuse airspace disease, presenting simultaneously with pulmonary edema and pleural effusions. Abnormalities in PT/PTT associated with NSTSS were commonly found within the first few hours of admission and began normalizing by the next day; d-dimer assays were abnormal in the six instances in which they were assessed. Conclusion This study suggests that early signs and symptoms of pediatric TSS may exist beyond those described by existing guidelines. The organ systems found to be involved in this review are often found early in the clinical course and can be assessed by noninvasive methods. Contextualization of these findings within the narrative of TSS might help clinicians better detect and diagnose a disease associated with significant patient morbidity and mortality. They may also aid in understanding the results of toxic shock surveillance efforts. Disclosures All authors: No reported disclosures.

2323. Unexpected Pediatric Presentation Patterns of Toxic Shock Syndrome