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Staphylococcal Toxic Shock Syndrome: A Case Presentation

This case presentation discusses a 19-year-old female who presents with diarrhea, vomiting, and a rash. The possible diagnosis is Staphylococcal Toxic Shock Syndrome.

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Staphylococcal Toxic Shock Syndrome: A Case Presentation

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  1. Case Presentation By Ahmed Abudeif Abd Elaal Resident in Tropical Medicine & Gastroenterology Department

  2. Case • 19 years old female • C/O diarrhea and vomiting. • Sudden onset, profuse for last 8-10 hrs • Some diffuse abdominal pain • Presents to ED in evening: • BP 100/65 P 95 T 37.8 • Looks anxious, feels weak, has been tolerating PO for last hour

  3. Case cont... • History of present illness: • No prodrome • No antibiotics in last 6 months • Not pregnant: started menses 3 days ago. • Travel: came back from Costa Rica 3 weeks ago, lived in families, has not been sick since • Past medical history: • No previous sexual history. • Never get pregnant.

  4. Case cont... • O/E: • Dry mouth. • Heart: Free. • Chest: Free. • Abdomen: Slightly distended, Bowel sounds +, diffuse tenderness, no guarding, no rebound. • Skin: Normal.

  5. Case cont... • Staff comes in... • Looks sick. • Asks for rectal T: 40. • Orders: • IV: 1L NS bolus • CBC, SMA-7 (BUN, Serum Cl, CO2, Creatinine, Blood glucose, Serum K and Serum Na), LFT’s, blood cultures • U/A and culture. • B-HCG. • Stool cultures, parasites, and C.Diff.

  6. Case cont... • Results: • WBC 13,500 • U/A : RBC ++++, 1-5 leukos • Creat 86 • Hb 13.9 • Platelets 190 • Urinary B-HCG -ve

  7. Case cont... • Diagnosed Pyelonephritis? • Started on Cipro • Observed in ER • 4 hrs later, weakness and syncope • BP: 90/40, confused • Non-pitting edema of face and neck • Sent to ressucitation • Volume ressucitated

  8. Case cont... • LABs repeated: • Creat 86, now 100 • Hb 13.9 now 9 • Platelets 190 now 100 • U/S abdomen and pelvis: • splenomegaly 16 cm • mesenteric adenitis • normal otherwise

  9. What is the possible Diagnosis?

  10. And now... • Patient develops a rash which is erythematous maculopapular :

  11. Case cont... • Our patient: • Blood cultures – ve • Monotest – ve • Vaginal swab + ve for staph aureus • Urine culture – ve • C. Diff – ve in stools • Specific toxins search at Winnipeg. Results pending.

  12. What is the possible Diagnosis?

  13. Staphyloccocal Toxic Shock Syndrome (STTS)

  14. STSS - Historical 1978 – Todd and Fishaut first describe STSS • Acute febrile illness in 7 children • Development of shock • Association w staphylococcus aureus 1981 –US epidemic • TSS identified in 941 pts • 812 menstrual cases; otherwise healthy women • Association w hyperabsorbant tampons use Drastic drop in incidence since 1980 Now 50% of case are non menstrual

  15. Toxic shock syndrome and tampons : the risk remains • US: annual incidence STSS: • 1-5 cases per 100 000 women in menstruation • > 90% in female 15-19y • Mortality 3.3%

  16. STSS – Risk factors • Menses • Tampons : increased risk 33 times in susceptible women • Nasal packing • Young age • Previous STSS • Vaginal – postpartum or following abortion • Surgical wounds: hernia repair, mammoplasty, arthroscopy • Septorhinoplasty • Influenza or influenza-like illness

  17. STSS – Pathogenesis • Toxic shock syndrome toxin-1 (TSST-1) • 90-100% of mentrual-related cases (MRTSS) • 40-60% of nonmenstrual cases (NMTSS) • Enterotoxin B: 23% • Enterotoxin C: 2% • Enhanced production: • Neutral vaginal pH • Increase in vaginal pO2 and pCO2 • Synthetic fibers in tampon composition

  18. STSS – Pathogenesis • TSST-1 & enterotoxins = Superantigens: • Nonspecific T-lymphocyte stimulation without normal antigenic recognition • Ad 20% Result: massive production of cytokines • Release of IL-1, IL-2, TNF, interferon

  19. STSS – Pathogenesis • Immune response from host plays an important role in pathogenesis • 70-80% of 18 y.o. have antibodies to TSST-1 • 90-95% at 40 y.o.

  20. STSS – Clinical presentation • Symptoms on presentation: • Tachycardia 80%. • Fever 70-81%. • Hypotension 44-65%. • Confusion 55%. • Localized erythema 44-65%. • Scarlatin-like rash 4%.

  21. STSS – Clinical presentation • Rapid onset of symptoms: • Day 3-4 of menses. • Day 2 post-operative.

  22. STSS – Clinical presentation

  23. STSS – Clinical presentation

  24. STSS – Diagnostic criteria • CDC 1990: Clinical manifestations • Fever >38.9. • Rash – diffuse macular erythroderma. • Desquamation – 1-2 after onset, palms and soles. • Hypotension (SBP<90 mmHg). • Multisystem involvement (3 or more): • GI (Vomiting, diarrhea, abdominal pain) at onset of illness. • Muscular (myalgias, CPK X2). • Mucous membrane (vagnal, oropharyngeal or conjunctival hyperemia). • Renal (Creat X2 or sterile pyuria). • Hepatic (bilirubin or ALT X2). • Hematologic (plt <100 000). • CNS (disorientation and alteration in consciousness).

  25. STSS – Diagnostic criteria • CDC 1990: Laboratory criteria • Negative results on the following tests , if obtained: • Serologic test for Rocky Mountain spotted fever, leptospirosis, measles • Blood, throat, CSF cultures (blood cultures may be + for Staph aureus)

  26. STSS – Diagnostic criteria • CDC 1990: Case classification • Definite case: all 6 criterias • Probable case: 5 on 6 criterias In the absence of clinical markers, strict application is warranted • Excludes subclinical cases • Self-limited

  27. STSS – Diagnosis • Isolation of Staphyloccocus aureus productor of exotoxins in a pt w compatible clinical picture • Not necessary for diagnosis • Help in suspected cases • RARELY isolated in blood

  28. Case cont... • Our patient: • Age 19 years old. • T > 38.9. • Diffuse rash. • Hypotension. • Multisystem involvement: • Diarrhea, Vomiting • Alteration in consciousness • Renal but not sufficient to meet the criteria • Plts 100 000 • Desquamation? Others tests – ve? • Probable case.

  29. STSS - Treatment • Treatment of support: • Agressive fluid support w isotonic NS or colloids: ad 10-20 L/24 hres • Vasopressor/inotrope infusion as necessary • Surgical treatment: • Removal of foreign objects: • Tampons • Nasal packing • Surgical debridement of scars: even if wound doesn’t look bad • I & D if abcess

  30. STSS - Treatment Therapy guided at stopping toxin production • Antimicrobial agents: • Have not been shown to affect outcome • IN VITRO: • Clindamycin inhibits protein synthesis – inhibition of TSST-1 • Anti-staph penicillin, cephalosporin may promote TSST-1 production • No clinical studies

  31. STSS - Treatment Therapy guided at stopping toxin production • Antimicrobial agents: • Recommandation: • Clindamycin 900 IV q8 +/- Cloxacillin 2g IV q12 • Clindamycin 900 IV q8 +/- Vancomycin 1g IV q12 for MRSA.

  32. STSS - Treatment • Additional therapies: • Consider Intravenous immunoglobulin (IVIG): • If patients remains unstable • Contains antibodies to TSST-1 • Sporadicaly reported to have salutary effect; controlled trials are incomplete • Corticosteroids: • May accelerate clinical improvement and diminish neurologic sequelae.

  33. Case: evolution • Treatment: • Cloxacillin + Tazocin IV X 2 d • then Cloxacillin IV x 4 d • then Cephalexin PO x 4 d • Hemodynamic stabilisation w 4 L NS and 2 L of Pentaspan the first night. • No need for inotropes or additionnal therapies. • Progressive improvement of general condition.

  34. Thank you

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