Prolonged use of a diaphragm and toxic shock syndrome

Abstract

A case report is presented that involves the extended use of a contraceptive diaphragm and illustrates the problems in promptly establishing a clinical diagnosis of staphylococcal toxin syndrome. A 27-year old woman, 2 months postpartum, was admitted to the hospital after 24 hours of fever, shaking, chills, sweats, nausea and vomiting, and diminished urine output. She had been unable to remove a new coil spring diaphragm, used for the 1st time since parturition, for 3-1/2 days before admission. On the day of admission the diaphragm was removed with some difficulty. A purulent, foul-smelling vaginal discharge at the time the diaphragm was extracted was noted. She was lactating and had had no menses since conception. Her past medical history was unremarkable except for mitral valve prolapse. Evaluation at the time of admission was remarkable for a pulse rate of 120 beats/minute and orthostatic lightheadness. The blood pressure was 110/70 mm Hg when the patient was supine and fell less than 15 mm Hg systolic when she was seated. The white blood cell count was 17,000 with 63% segmented and 33% juvenile polymorphonuclear leukocytes. The sedimentation rate was 45 mm/hour. Multiple cultures of vagina, throat, urine, and blood were obtained. Vigorous intravenous fluid and electrolyte therapy was administered, and the patient was initially begun on ampicillin and tobramycin. Shortly after the appearance of the rash, staphylococcal toxic shock syndrome (TSS) was suspected, and the ampicillin was changed to oxacillin. The rash and strawberry tongue faded within 24 hours, and she became normotensive and afebrile by the 2nd hospital day. She was changed to oral dicloxacillin as the only antibiotic on the 4th hospital day, after the culture results were confirmed. At the time of discharge on the 6th hospital day, desquamation of the skin on the palms and soles had started and continued for another 7-10 days. A 10 day course of dicloxacillin was completed. Follow-up vaginal, cervical, and pharyngeal cultures 3 and 5 months later contained no S. aureus. The patient had resumed menstruation but was not using tampons or a diaphragm. Increased vigilance for the potential dangers of using vaginal occulusive devices when the lower genital tract is colonized by S. aureus is necessary.