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