Morning Report: 4/17/2014 - The Original Kings of County

Thanks to Dr. McMillan for today’s Morning Report!

Here’s the Case:

21 year-old recently postpartum female presents with chief complaint of diffuse, red rash started shortly before calling EMS. Paramedic notes that she looks like anaphylaxis, but he didn’t give epinephrine due to no respiratory involvement. She is diffusely sunburnt-red throughout her face body. Shortly after arrival she complains of light-headedness and seeing spots, and her blood pressure is 60 systolic, heart rate 130 bpm. Her blood pressure and heart rate remain unchanged after 2L NS bolus under pressure.

What’s the Dx?

Toxic Shock Syndrome

Two organisms that cause toxin mediated toxic shock syndrome:

1. Group A Streptococcus (GAS) aka Streptococcus pyogenes

2. Staphylococcus aureus

First popularized in 1980 when large number of cases in young women – almost all menstrual cases associated with highly absorbent tampons
Now more nonmenstrual cases than menstrual – can be from mastitis, postoperative wound infections, sinusitis, postpartum infections, etc.

Pathophysiology: Primarily due to Toxic shock syndrome toxin-1 (TSST-1), but also other toxins. They act as “superantigens”, activating up to 20% of all T cells, resulting in massive cytokine production. 80-90% of cases have S. aureus isolated from mucosal or wound sites.

Clinical Presentation

Fever
Hypotension
Skin changes

Additional signs and symptoms: chills, malaise, headache, sore throat, myalgias, fatigue, vomiting, diarrhea, abdominal pain, orthostatic dizziness or syncope

Management is primarily supportive, with some responding to fluids alone, others may need significant vasopressor support. Refractory shock frequently associated. Source control is very important. Must exam vaginal canal for foreign bodies, address surgical wounds (even well-appearing wounds may harbor toxin producing bacteria, and must be explored and debrided if patient meets criteria for TSS). Send cultures of vaginal canal/wounds.

Antibiotics indicated, staphylococcal coverage indicated.

– Clindamycin 600 mg IV q 8hrs

– plus Vancomycin 15-20 mg/kg/dose q8-12hrs

– ? IVIG (more effective in streptococcal toxic shock)

Prognosis

Mortality rate relatively high: Appx 1.8% for menstrual cases, 6% for nonmenstrual cases, and 3-5% in children overall.

Reference

Chu, VH. Staphylococcal toxic shock syndrome. In: UpToDate, Sexton DJ and Kaplan SL (Eds), UpToDate, Waltham, MA. (Accessed on March 30, 2014).

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital