A 21 year-old male presents to your ED with complaints of fever, rash, and generalized malaise. His triage vitals are HR 112, BP 95/55, RR 22, POx 98%, T 102.3F. When you go into the room to exam him, you notice a tampon in his right naris. When you ask him about it, he tells you it is a part of his fraternity pledging exercise. His fellow pledge brothers have to compete to see who can keep the tampon in their nose the longest. This began 5 days ago.
What is the most likely diagnosis, and what is the pathophysiology?Toxic Shock Syndrome (TSS): A deadly, toxin-mediated illness that causes high fevers, hypotension, rash, and multiorgan involvement.
Staphylococcus aureus produces exotoxins, namely TSS1 and enterotoxin B. These toxins act as superantigens, which stimulate a large number of T cells to produce a massive cytokine reaction.
TSS is normally associated with prolonged tampon use during menstruation or theoretically, nasal packing.
Normally, an antigen has to be recognized and processed by an antigen-presenting cell. The antigen-presenting cell then expresses the antigen along with class II major histocompatibility complex (MHC). Only T cells with the appropriate receptor that recognizes the antigen and then MHCs are activated and produce cytokines.
Superantigens do not require processing and are able to activate antigen presenting cells and T cells directly. As a result, they active many more T cells and cause a hyperimmune response. Video here
TSS rashes are erythematous, diffuse, macular, and blanching. This rash can desquamate the palms and soles after 1-2 weeks of disease onset. TSS rashes have been described as “painless sunburn.”
As mentioned previously, TSS is usually associated with fever, desquamating rash, and hypotension. Other systemic effects include:
- GI: Diarrhea and/ or vomiting
- MSK: Myalgia, elevated CPK
- Renal: Acute kidney injury with elevated BUN and creatinine
- Hepatic: Liver injury with elevated liver enzymes
- Hematologic: Decreased platelet count
- CNS: Altered mental status
Treatment for TSS involves removing the offending agent, supportive care for septic shock, and antibiotics. Supportive care measures include antipyretics, fluids, and possibly vasopressors.
Antibiotics against staph aureus include nafcillin or oxicillin 2g every 4 hours, clindamycin 600-900mg every 8 hours, or in cases of MSRA, vancomycin 1g every 12 hours. Antibiotic treatment is aimed at eradicating remaining staph aureus to stop exotoxin production.
References:
Perry, Shawna J., and Reneé D. Reid. “Chapter 145. Toxic Shock Syndrome and Streptococcal Toxic Shock Syndrome.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2011.
Remember, what we know from evidence and do in practice may not always be the right answer on the exam. Frustrating, I know, but are you shocked?
Special thanks to Dr. Willis and Dr. deSouza
Karen
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