CASE PRESENTATION ``Heroes`` Isabel Alonzo-Proulx, CCFP(EM)
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Transcript of CASE PRESENTATION ``Heroes`` Isabel Alonzo-Proulx, CCFP(EM)
CASE PRESENTATION``Heroes``
Isabel Alonzo-Proulx, CCFP(EM)
Case
19 y.o.,female c/o diarrhea and vomiting Sudden onset, profuse for last 8-10 hrs Some diffuse abdo pain Presents to ED in evening:
BP 100/65 P 95 T 37.8b Looks anxious,feels weak, has been
tolerating PO for last hour
Case cont...
HPI: Ø prodrome Ø antibiotics in last 6 months Ø pregnant: started n menses 3 days ago Travel: came back from Costa Rica 3 weeks
ago, lived in families, has not been sick since PMHx:
Ø previous Sx Never pregnant
Case cont...
O/E: Mucous are dry CV n Pneumo n Abdomen: slightly distended, BS+, diffuse
tenderness, no guarding, no rebound
CVA equivocal bilat Skin n
Case cont...
Staff comes in... Looks sick Asks for rectal T: 40 Orders:
IV: 1L NS bolus CBC, SMA-7, LFT’s, blood cultures X2 U/A and culture B-HCG Stool cultures x2, parasites, and C.Diff
Case cont...
Results: WBC 13 500 U/A : RBC ++++, 1-5 leukos Creat 86 Hb 139 Platelets 190 Urinary B-HCG -
Case cont...
Dx Pyelonephritis? Started on Cipro Observed in ER
4 hrs later, weakness and syncope BP: 90/40, obtunded Non-pitting edema of face and neck Sent to ressuc Volume ressucitated
Case cont...
Hypothesis? DDX ?
Case cont...
LABs repeated: Creat 86, now 100 Hb 139 now 90 Platelets 190 now 100
U/S abdomen and pelvis: splenomegalia 16 cm mesenteric adenitis n otherwise
Case cont...
DDx:Acute pyelonephritis?Septic shock?PID?HUS?Leptospirosis?
Gastroenteritis?
Tick Typhus?
And now...
Pt develops a rash:
Case cont...
DDX :
Kawasaki disease?
Reye syndrome?
Erythema multiforma?
Rocky Mountain spotted fever?
Staphyloccocal Toxic Shock Syndrome
Staph TSS
Staphylococcus
Gram positive cocci:
S.Aureus - Pathologies
Local invasion and tissular destruction: Impetigo Cellulitis Endocarditis ...
Toxin mediated TSS Staphyloccocal exfoliation syndrome Food poisoning
S. Aureus - Epidemiology
Reservoir – Human Asymptomatic carriers:
Naso-pharynx Rectum Perineum: 98% of women w TSS compared w control
subjects
Cutaneous colonisation – brief, repetitive Transmission – person to person
S. Aureus – Carrier rate
Population
General population
HD patients
DB insulin
Desensitivation therapy patients
IV drug users
Carrier rate (%)
25
75
50
50
40
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 1980Now 50% of case are nonmentrual
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%
Therapeutic Product Directorate: TPD-Web
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
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
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
STSS – Pathogenesis
Immunitary 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.
Pts who dev STSS are unable to produce antibodies Frequent recidival
STSS – Clinical presentation
Sx on presentation: Tachycardia 80% Fever 70-81% Hypotension 44-65% Confusion 55% Localized erythema 44-65% Scarlatin-like rash 4%
STSS – Clinical presentation
Rapid onset of sx: Day 3-4 of menses Day 2 post-operative
STSS – Clinical presentation
STSS – Clinical presentation
STSS – Dx criteria
CDC 1990: Clinical manifestations Fever >38.9 Rash – diffuse macular erythrodema Desquamation – 1-2 after onset, palms and soles Hypotension (SBP<90 mmHg) Multisystem involvement(3+):
GI (V, diarrhea, abdo pain) Muscular (myalgias, CK X 2) Mucous membrane (vagnal, conjunctival hyperemia) Renal (CreatX2 or sterile pyuria) Hepatic (bili or ALTX2) Hemato (plt <100 000) CNS (disorientation and alteration in consciousness)
STSS – Dx 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)
STSS – Dx 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
STSS – Dx
Isolation of Staphyloccocus aureus productor of exotoxins in a pt w compatible clinical picture Not necessary for dx Help in suspected cases RARELY isolated in blood
Case cont...
Our patient: T> 38.9 Diffuse rash Hypotension Multisystem involvement:
Diarrhea, V Alteration in consciousness Renal but not sufficient to meet the criteria Plts 100 000
Desquamation? Others tests – ? Probable case
Case cont...
Our patient: Blood cultures – Monotest – Vaginal swab + for staph aureus Urine culture – C. Diff – in stools Specific toxins search at Winnipeg. Results
pending.
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
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 peni, cephalosporin may promote TSST-1 production
No clinical studies
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
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
neuro sequelae
Experimental agents
Case: evolution
Tx: Cloxacillin + tazocin IV X 2 d then cloxacillin IV x 4 d then Keflex 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