Toxic Shock Syndrome

Patient presentation:
16-year old, B.J. presents to ED with sudden confusion. Her mother states approximately 1 hour ago B.J. was speaking to her when suddenly her sentences became jumbled and inappropriate. Currently B.J. has a staring gaze, responds inappropriately to commands and is not oriented to person, place, or time. She is pale with a slightly yellow cast, her skin is clammy, the palms and soles of her feet are covered in a sunburn like rash, and her conjunctiva and mouth are erythematic. Mom states that B.J. has been feeling ill for past 2 days with nausea, vomiting, diarrhea, general malaise and body aches and thought she was suffering from the flu. B.J. has no significant medical or surgical history. No recent travel. Upon further questioning mom states that she was concerned that B.J. also started having a very heavy period approximately 4 days ago and she is concerned with blood loss. B.J. proceeded to have a 45 second seizure and maintained a postictal state for approximately 2 hours.

VS: Temp-103.2, BP-74/38, Pulse-110 and thready, RR 14

Differential list:
Toxic Shock Syndrome, Septicemia/Shock

Diagnosis:
The following labs were ordered: CBC, CMP, Creatine Phosphokinase, and cultures of urine, blood, vagina and CSF.

CBC - WBC 22,000/mm3, platelets 89,000/ml
CMP- Total Bilirubin- 3.1mg/dl, ALT 75 U/l, AST 176 U/l, BUN 41mg/dl, Creatinine 3.6 mg/dl
Urine Culture - unremarkable
Culture of vagina - During sterile speculum exam, 7 ml of pus and a tampon were found and removed. Site positive for Staphylococcus aureus
Culture of blood - positive for Staphylococcus aureus
Culture of CSF - negative
Creatine Phosphokinase -300 U/L

Based on the presence of Staphylococcus aureus in blood and vaginal cultures, and the other symptoms, the diagnosis was toxic shock syndrome.

Treatment:

Aggressive fluid replacement was initiated with NS & FFP.
Vasopressors
Nafcillin 2g IV every 4hrs
Cefazolin 2g IV every 6hrs
Oral anti-staphylococcal ABx for following 10 -14 days

Outcome:
B.J. stayed in ICU for 3 days receiving dialysis. She was then transferred to a med/surg unit for 2 days of monitoring and continued oral antibiotic treatment. Pt developed classic diffuse body rash and peeling of skin but felt well. Discharged on day 6.

Case created by Brittany Johnson, 2011.