Toxic Shock Syndrome 06.22.2015

8/20/2019 Toxic Shock Syndrome 06.22.2015

1/21

17 year old male

with 1 day of fever andrashScott Wallace MD PGY 2

Morning report 6221!


2/21

"P#

• Patient presents to clinic with fever and $%ody aches&since last night'

• Mother reports that patient was healthy and acting

normally prior to last night when he developed fever to1() followed %y generali*ed aches'

• Patient reports that he then developed headache and

nec+ ache this morning ,appro-imately . ho/rs ago0

• Patient also developed whole %ody erythemato/snonpr/ritic rash this morning'


3/21

"P#

• Patient was recently diagnosed with streppharyngitis via rapid strep test at /rgentcare' #s c/rrently on day of 1( of penicillin'

• Patient recently ret/rned from 3hailand )wee+s ago where he was on a service trip inr/ral 3hailand' – 3here patient c/t his left shin on a %oat' Patient

was staph positive on c/lt/re in /rgent care andstarted on 4actrim' #s c/rrently on day of 1('


4/21

"P#

• Patient reports fatig/e on 5S

• Patient reports no drainage or redness from

left shin wo/ld' Denies any pain at wo/nd'

• Patient and mother deny any co/ghcongestion na/sea vomiting diarrhea

a%dominal pain oint painswelling sorethroat chest pain dyspnea'


5/21

"P#

89PS:58 "#S35Y;

• Swam in rivers in 3hailand

•


6/21

More "istory

• PM"; steoma removed 2 years ago'


7/21

89?M;BS; 3 .('! "5 C 55 1C 4P 12C72 Sats C on room air'

G8


8/21

S/mmary slide

• 17 year old male with 1 day of fevermyalgia headache and rash'


9/21

DD9 #nfections

– Gram negative sepsis

–

Staph ?/reas• 3SS

• Scalded S+in

– G?S

• 3o-ic Shoc+ syndrome

•


10/21

DD9 Eontin/ed

• EB

– 8ndocarditis

• 5he/m – 5he/matic @ever

– >awasa+i

– SF8

– polymyalgia rhe/matica

– Dermatomyositis

• "emeonc

– Fe/+emia

– Fymphoma

– Solid t/mor


11/21

Eo/rse;

• Patient in the 8D initial vitals; 3 .('! "5122 4P 1166 sating 1(( on 5?

• 8D co/rse; "e was given 2 %ol/ses of


12/21

Fa%s

• E4E; W4E 6') ,1C4 6!PM


13/21

Eo/rse

• Patient maintained on vanc clindaand ceftria-one initially'

• N/ic+ly weaned oH pressors' 3ransferred to Koor on "D O1

• Bancomycin and Eeftria-onediscontin/ed at .C ho/rs negativec/lt/res'

• Elindamycin contin/ed for 1( dayco/rse' Patient discharged on "DO)


14/21

3o-ic Shoc+ Syndrome

• #nitially descri%ed in 17C – #nitially seen predominately in

menstr/ating females• Medial interval %etween onset of

menstr/ation and symptoms is 2J) days,similar time for posts/rgical0

–


15/21

Staphylococcal 3o-ic Shoc+Syndrome

• Ea/sed predominately %y MSS? – D/e to 3SS3J1 or enteroto-ins ,? 4 E D 8 and "0

–


16/21

S+in Manifestations inStaphylococcal 3SS;

•

involves s+in and m/co/s mem%ranes• can involve palms and soles

• Severe cases can ca/se %/llae andpetechiae

• Fate onset ,1J2 wee+s0; can getdes=/amation


17/21

EDE Diagnostic Eriteria

• M/st have – @ever )C'

– "ypotension

– DiH/se erythroderma – Des=/amation ,/nless patient dies prior0

– #nvolvement of at least ) organ systems

– #f missing one of these criteria then can %epro%a%le 3SS

– Do not re=/ire isolation of Staph a/re/s


18/21

Streptococcal 3SS

• Similar presentation

• 5is+ factors; – 1(years old or 6( cancer renal

fail/re %/rns or imm/ne s/ppressed

– ?ssociated with minor tra/mas


19/21

Diagnostic criteria

• #solation of G?S from a normally sterile site

• "ypotension

• Pl/s 2 of the following – 5enal dysf/nction – Eoag/lopathy

– Fiver dysf/nction

– ?c/te 5DS

– 8rythemato/s mac/lar rash ,may des=/amate0

– Soft tiss/e necrosis ,nec fasc myositisgangrene0


20/21

Management of 3SS

• S/pportive therapy with #B@spressors etc

• S/rgical drainage of identiAed sites ifpresent

• 8mpiric ?%-; Bancomycin andElindamycin

• #f MSS?; Elindamycin and o-acillin ornafcillin

• #f M5S?; Elindamycin andvancomycin or line*olid


21/21

5eferences;

• 5ed%oo+ 2(1!

• :ptodate – http;www'/ptodate'comcontentsstaphylococ

calJto-icJshoc+JsyndromeRso/rcesearchTres/ltUsearchto-icshoc+syndromeUselected3itle1781(!

– http;www'/ptodate'comcontentsepidemiolo

gyJclinicalJmanifestationsJandJdiagnosisJofJstreptococcalJto-icJshoc+JsyndromeRso/rcesearchTres/ltUsearchto-icshoc+syndromeUselected3itle2781(!

Toxic Shock Syndrome 06.22.2015

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