Senior Report 5.21

Case Presentation by Dr. Sarah Albers

CHIEF COMPLAINT(S):

“She has got a fever and is throwing up.”

HISTORY OF PRESENT ILLNESS:

A 16-year-old Caucasian female presents with both of her parents to the emergency department.  The adolescent girl complains of “not feeling well over the past one day.”  She feels dizzy, which she describes further as persistent wooziness that is not positional; there is no sensation that she or the room is spinning. She also feels nauseous, and has a headache – described as a tight band around her temples, with no blurriness of her vision, or change in her vision or hearing. No history of trauma or falls.  She also has generalized myalgias, a sunburn like rash over her trunk, back and upper extremities, redness to her eyes, chills and a fever that started abruptly a couple of hours ago; her temperature was 104 F at home and she took Tylenol, but then vomited it back up.  She states that it hurts her muscles when she takes a deep breath.  She has had no cough or chest pain. She denies shortness of breath or difficulty breathing. No runny nose or sore throat.  No leg pain.  She says she is just feeling “generally weak and my whole body hurts.”

She has had nausea and vomiting today, approximately 10 to 20 episodes of emesis that have been nonbloody, nonbilious.  She has been unable to keep anything down except for a little bit of water and ice chips.  She denies any abdominal pain, blood in her stools, or any black tarry stools.  She states she has bowel movements regularly; her last bowel movement was today with no diarrhea or constipation.  She denies any dysuria, urgency or frequency.  She denies any vaginal discharge, but is currently on her period.

She said she started feeling a little bit “bad” last night with the beginning of a headache; however, today was when everything “hit” her.  She describes as all of these symptoms coming on suddenly.  Mom states she has not been hospitalized nor has she been treated with antibiotics over the past 2 months.  Two months ago she was treated for pneumonia.  She is currently on a homoeopathic medication for Candida called Threelac.  Otherwise, this child is healthy and takes no medications. She has no known sick contacts.

REVIEW OF SYSTEMS:

CONSTITUTIONAL:  Positive fever & chills.

EYES:  No change in vision.  Positive red eyes.

ENT:  No change in hearing, runny nose, or sore throat.

RESPIRATORY:  No wheezing, cough, or hemoptysis.

CARDIOVASCULAR:  generalized muscle soreness of her chest wall when taking deep breaths, otherwise no pain.  No palpitations or edema.

GI:  Positive nausea & vomiting.  No diarrhea or constipation.  No black tarry stools or bright red blood per rectum.

GU:  No dysuria, urgency, or frequency.  She is currently on her menstrual cycle.  She does use tampons, and currently has one in.

MUSCULOSKELETAL:  Positive myalgias.  No injury or trauma.

SKIN:  Positive erythematous rash over her trunk, arms, and back.

CNS:  Generalized weakness, no syncope, numbness, speech deficit, confusion or altered mental status.

PAST MEDICAL, FAMILY, AND(OR) SOCIAL HISTORY:

PAST MEDICAL HISTORY:  None.  However, recent treatment for pneumonia and the patient is currently being treated with a homeopathic medication for a possible candida infection.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  Include a homeopathic called Threelac to treat Candida.  She is also taking a “digestive enzyme”.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY:  negative for hypertension or diabetes

SOCIAL HISTORY:  Negative for tobacco, alcohol, and drugs.  The patient is not currently sexually active.  She has never had sex in the past.  They do have working smoke detectors in the house.  She does always wear a seatbelt in the car.  There are no guns in the house. She does do well in school.

EXAMINATION OF ORGAN SYSTEMS-BODY AREAS:

VITAL SIGNS:  On arrival, her blood pressure 111/90, heart rate of 122, respiratory rate is 18, temperature is 39 orally, pulse ox is 95% on room air.

CONSTITUTIONAL AND GENERAL:  The patient is a tall, thin, well-developed, well-nourished female, in no acute respiratory distress, speaking in full sentences, cooperative for exam, A and O x3. She is nontoxic appearing.  She smiles on exam and converses with her parents and me and jokes around a bit. She is sitting upright on the stretcher with her legs drawn up in front of her with her arms wrapped around her legs.  She is wearing a patient gown.  She does have slightly reddened eyes as well as reddish hue to her arms on observation.

HEENT:  Head is normocephalic, atraumatic.  No acute masses or lesions.  Eyes:  Pupils are 3 mm, round and reactive to light.  Extraocular movements are intact.  No conjunctival pallor.  Sclerae are anicteric.  Sclerae are also injected bilaterally.  No evidence of discharge in her eyes.  Nose: no nasal discharge is noted.  Ears:  Tympanic membranes are clear bilaterally. Landmarks are clearly visualized. Mouth and throat:  Mucous membranes are moist.  No erythema, tonsillar exudates or intraoral lesions.

NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  No tenderness to palpation of the cervical spine.  Trachea is midline.  No meningismus or nuchal rigidity.

LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.  Good air exchange in all lung fields.

HEART:  S1, S2 are present.  Tachycardic rate and regular rhythm, pulses in all four extremities are equal and 2+.

BACK:  No cervical, thoracic, lumbar or sacral spinal tenderness.  The patient has no CVA tenderness.

EXTREMITIES:  No clubbing, cyanosis or edema.

SKIN: The patient does have an erythematous, first degree sunburn-looking rash on the anterior aspect of her bilateral upper extremities as well as her anterior and posterior chest and abdominal wall.  It is blanching in nature.  There are a few very tiny papules on the area of her anterior forearm.  There is no sloughing of skin or bullae formation.  There is no blistering of the skin.  Skin is not tender to touch.  Skin is warm to touch throughout.  She has no erythema or rash on her palms or soles.  She has no rash or erythema on her bilateral lower extremities.

GU:  Performed in the presence of a female nurse chaperone shows normal, Tanner Stage 5, female external genitalia. On speculum exam a tiny amount of blood in the vaginal vault, patient is currently menstruating.  No tampon is present. There is a closed cervical os.  The patient does have pain on insertion of the speculum.  Swabs were obtained. The patient does have cervical motion tenderness as well as bilateral adnexal tenderness. No masses were palpitated. There are no excoriations or sores on the inside of the vaginal vault. Microscopy was negative for trichomonas or clue cells.

NEUROLOGIC:  The patient is awake, alert, and oriented x3.  Normal speech and hearing to finger rub.  Face is symmetrical.  No nystagmus is present.  Sensation is equal and intact throughout.  Motor strength is 5/5 in all four extremities.  The patient does ambulate with a normal gait.

Questions:

1)    At what point does the accepting hospital assume responsibility for a transfer patient?

  • a.  as soon as the transporting service (ambulance, helicopter) reaches the accepting hospital grounds
  • b.  half-way through transit, when the accepting facility is closer than the  sending facility
  • c.  when the patient arrives inside the accepting facility doors
  • d.  when the patient leaves the sending facility

2)    Which of the following is most likely to predispose a patient to this condition?

  • a.  niacin use
  • b.  recent antibiotic use
  • c.  recent seafood ingestion
  • d.  tampon use

3)    What condition is the patient most likely suffering from?

  • a.  drug-induced dermatitis
  • b.  Stevens-Johnson syndrome
  • c.  toxic epidermal necrolysis
  • d.  toxic shock syndrome

Answers:

1. d

2. d

3. d (Staph Aureus) Toxic shock syndrome from tampon use

Discussion:

Toxic Shock Syndrome (TSS) is characterized by severe prolonged shock and is caused by a toxin produced by S. Aureus. This was originally described by Todd et al. in 1978.  They reported a series of 7 cases of kids 8-17, S. Aureus was cultured from various body sites, but not the blood, in 5 of the 7 cases.  Most of the subsequent cases have occurred in menstruating females often after a menstrual period associated with tampon use.  In the early 1980’s the consistency of tampons were changed to reduce absorbancy due to growing concerns about TSS.  In the late 1980’s group A Streptococcal toxic shock syndrome (strep TSS) was described because it shares so many feature with TSS.

Menstruation and tampon use is the most common setting for TSS, but non-menstruation TSS accounts for just under half of the reported cases.  Of these cases, strep TSS account for just over half of the cases. Nonmenstrual TSS is associated with super infections of skin including burns, surgical sites, dialysis catheters and lung (influenza associated). It can also happened in association with staph respiratory infections or colonization without an obvious infection source. Strep TSS is classically associated with more severe soft tissue infections including necrotizing fasciitis and myositis, as well as pneumonia, peritonitis, myometritis and osteomyelitis. Mortality reaches 30-70% in strep TSS, and in staph TSS it is <3%.

Staph TSS is caused by the colonization or infection with toxigenic strains, specifically TSST-1 (toxic shock syndrome toxin – 1). Because the organism is not invasive, blood cultures are often negative. Strep TSS is caused by invasive infection with toxigenic strains of GAS (Group A Strep).

The clinical presentation of Strep TSS and staph TSS is similar. The primary difference is that an identifiable source is virtually always present with strep TSS and colonization alone may lead to staph TSS.

Clinical presentation:

Patients may present with fever, chills, nausea, vomiting, diarrhea, headache, myalgias, and pharyngitis.  Prodrome may last hours to 2 or 3 days. The fever is usally high and abrupt in onset (although septic patients may be hypothermic).  The classic rash is a nonpuritic, diffuse, blanching, macular erythroderma.  Initially, this may be mistaken as flushing due to fever.  The rash is typically diffuse but may be localized to the trunk, extremities or perineum.  After about a week a fine flaking desquamation occurs of the face, trunk and extremities followed by full thickness peeling of palms, soles and fingers. This classic rash is much more common with staph TSS and is present in less than 10% of patients with strep TSS.

TSS Rash

Toxic shock syndrome. A. Appearance of the rash associated with staphylococcal toxic shock syndrome (TSS). B. Gangrenous toes associated with prolonged hypotension in TSS. C. Desquamation of the skin that occurs during the resolution of TSS.

http://5minuteconsult.com/ViewImage/2027438

The patient’s mental status is frequently abnormal, out of proportion to the hypotension that ensues. Confusion, somnolence, agitiation and combativeness are present in 55% of strep TSS and even more frequent in patients with staph TSS. Other physical findings include pharyngeal and conjunctival erythema, strawberry tongue and peripheral edema. Vaginal mucosal erythema and purulent vaginal discharge may be present in menstrual TSS. As more organ systems become involved a wide range of signs and symptoms may be seen.  GI involvement manifests itself by nausea, vomiting, diarrhea and abdominal pain.  Hepatomegaly may be present. Patients may become hypoxic and develop rales on lung examination.

Comparison for staph and strep TSS

Feature Staph Strep
Age Primarily 15-35 years Primarily 20-50 years
Sex Women > men Women = men
Severe pain Rare Common
Hypotension 100% 100%
Erytheroderma rash Very common Less common
Renal failure Common Common
Bacteremia Low 60%
Tissue necrosis Rare Common
Predisposing factors Tampons, packing, ?NSAID use? Cuts, burns, bruises, varicella, ?NSAID use?
Thrombycytopenia Common Common
Mortality rate 3% 30-70%
  • Risk Factors for TSS
  • tampon use
  • postoperative wound infections
  • postpartum period
  • nasal packing
  • cancer
  • common bacterial infections
  • ETOH abuse
  • infection with influenza A
  • infection with varicella
  • Diabetes
  • HIV
  • Chronic cardiac disease
  • Chronic pulmonary disease
  • NSAID (may mask symptoms rather than be a risk factor)

Diagnosis:

 The case definition for TSS does not require a positive culture for S. Aureus, but a positive culture is required to diagnose strep TSS. Specific tests are not required to rule out other diseases, but if such tests are obtained the results must be negative.

No specific laboratory changes are associated with TSS, but many abnormalities are common including: leukocytosis or leukopenia, bandemia (very common), elevated creatinine and hemoglobinuria, hypoalbuminemia and hypocalcemia. Other abnormailities include anemia, thrombocytopenia, hyperbilirubinemia, elevated transaminase levels and sterile pyuria.

A lumbar puncture should be performed on febrile patients with altered mental status to evaluate for meningitis. It is prudent to wait for the coagulation profile before the LP, as DIC may exist at the time of presentation. The CSF is normal in TSS.

Management:

TSS patients should receive aggressive fluid resuscitation with crystalloids and may require up to 10-20 L a day! Supplemental oxygen should be provided to all septic patients regardless of initial pulse ox. This will allow for maximal tissue oxygenation and reduces acidosis. They should have continuous cardiac and pulse oximetry monitoring.

The source of bacteria (tampons, nasal packs and other foreign bodies) must be removed immediately.  (On our case patient, ROS stated tampon was in and on pelvic exam tampon was out).  Prompt surgical consultation should be obtained to debride wounds. If specimens are sent for culture, the lab should be informed of the suspected diagnosis.

Patients who do not respond to fluids require vasopressors.  Antibiotics (broad spectrum) need to be initiated early in TSS.  Clindamycin is recommended, as it is a potent suppressor of bacterial toxins (dose is 600-900 mg IV q 8h or peds dose is 20-40 mg/kg/day divided every 6-8 hours).


Disposition:

All patients thought to have TSS should be admitted to an ICU!  Again, prompt surgical intervention should be obtained for patients with a wound source.

So back to our patient…

16-year-old adolescent girl presenting with suspected TSS from tampon use.  We had her immediately remove her tampon.  (Note tampon in on ROS, but not during pelvic). On re-evaluation, repeat BP was 70/30-50’s and lab work returned showing:  elevated lactate, acute renal failure, leukocytosis, mild elevation in coags (PT/INR).

ID was consulted and recommended broad spectrum abx including clindamycin, vancomycin and ceftriaxone, which were all started. BP remained at 70’s systolic after 5 L of crystalloid fluids.  Fever and vomiting was controlled with IV NSAIDS and antiemetics.

Patient’s mental status remained AOx3 the entire time, she never looked toxic, continued to smile on exam and wanted to continually walk to the bathroom.  Decision was made to transfer to CHM PICU as a direct admission, CHM requested we not start pressors or a central line at our facility.  They did send PANDA to come get this patient by helicopter.  She ended up on three pressors; dobutamine, Dopamine and vasopressin (all were weaned by hospital day 3) at CHM in the PICU after a femoral line was placed.  Same antibiotics were continued.  Vaginal swab grew Staph Aureus (MSSA), GC and Chlamydia were negative. Blood cultures were negative.  Urine culture grew staph coagulase positive.  After three days in the PICU she was transferred to the ID service and then discharged after one day on the floor.  She was sent out with a 3-week course of clindamycin.  She developed C. Difficile colitis and was treated with oral flagyl and vancomycin.

2 Responses

  1. Question 1 has incorrect answer. As a receiving physician, you are not liable for a patient with which you have never had contact. Please give references if you are under a different understanding.

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