Toxic Shock Syndrome following Septoplasty: Report of 2 Cases and Literature Review

Abstract

Objectives: Toxic shock syndrome (TSS) is a rare but potentially life-threatening multisystem disease. Reported incidence after nasal surgery is 16.5 per 100,000 operations. We report 2 such cases from Northern Ireland occurred over last 8 years (2006 and 2012). Diagnostic criteria, pathogenesis, and management of TSS are discussed. Methods: Case 1: A 19-year-old man developed sudden severe facial swelling, fever, diffuse erythroderma, tachycardia, and hypotension 16 hours after routine septoplasty and cautery to inferior turbinates. He had sialastic internal nasal splints and calcium alginate packing. Initially anaphylaxis to latex or diclofenac was suspected but disproved by lab investigations. He had surgical tracheotomy to protect airway from progressive facial cellulitis. Nasal swab confirmed grown staphylococcus aureus (TSST-1 producing-strain), and he recovered slowly with antibiotics. Case 2: A 24 year- old man developed a mild form of TSS 36 hours post-surgery after routine septopasty and Merocel packing, with nausea, hypotension, tachycardia, fever, and erythroderma. TSS was promptly suspected. The patient moved to intensive care for supportive care of refractory hypotension, and he made a slow recovery with antibiotics. Nasal swab had grown staphylococcus aureus. (TSST-1 strain). Results: TSS cases following nasal surgery have been associated with nasal packing, mucosal barrier violation, and prior colonization of toxic-shock-syndrome-toxin-1 (TSST-1) strain as well as low antitoxin antibody levels. Hence TSS requires nasal carriage of a toxigenic strain of staphylococcus aureus by a susceptible patient. Topical or systemic antibiotics did not have a demonstrable protective effect. Conclusions: Early recognition and prompt intervention minimize the morbidity and mortality associated with this disease.