Case Of Toxic Shock Syndrome Research Articles

472. Rethinking the Role of Clindamycin for Toxin-Mediated Illnesses

BackgroundTreatment of toxin-mediated diseases such as toxic shock syndrome (TSS) and Staphylococcus scalded skin syndrome (SSSS) typically includes adjunctive clindamycin to halt bacterial exotoxin production. However, there is emerging clindamycin resistance in Staphylococcus aureus and Streptococcus pyogenes. We compared pathogen susceptibilities, clinical features, and outcomes of patients with toxin-mediated diseases to evaluate the role of adjunctive clindamycin in a contemporary setting.MethodsEpic was queried for patients < 18 years of age admitted to Inova Fairfax Hospital from January 1, 2009 to December 31, 2018. Patients were identified by ICD-9 and ICD-10 codes for TSS and SSSS and validated by manual chart review. TSS cases were classified as possible, probable, or confirmed, and SSSS cases were classified as probable or confirmed. Early antimicrobial use was defined as administration within the first 3 days of admission. Clindamycin, aminoglycosides, tetracyclines, and linezolid were considered antimicrobial agents with anti-toxin effect.ResultsThere were 32 cases of TSS, 38 cases of SSSS, and 1 case of bullous impetigo. S.aureus (30) and S.pyogenes (8) were the most common pathogens recovered with 1 case of MRSA. Vancomycin was given to 40 patients. 45% of S.aureus isolates were clindamycin resistant; no S.pyogenes isolates were clindamycin resistant. Fifty-eight patients received early anti-toxin agents: 51 received clindamycin, 4 received clindamycin and doxycycline, 1 received clindamycin and gentamicin, 1 received doxycycline, and 1 received gentamicin. 13 did not receive any early anti-toxin agent. 42% of patients who received early clindamycin had a clindamycin-resistant S. aureus. The presenting features, number of TSS and SSSS cases, need for intensive care, median length of stay, and 30-day readmissions did not significantly differ based on early anti-toxin agent use or based on clindamycin susceptibility. There were no deaths.ConclusionWithholding anti-toxin agents early in the course of illness or giving clindamycin to a resistant organism in toxin-mediated diseases did not adversely affect patient outcomes or mortality. Opportunities remain to decrease the use of empiric vancomycin and re-evaluate the role of clindamycin for toxin-mediated diseases.Disclosures All authors: No reported disclosures.

Epidemiology and Clinical Relevance of Toxic Shock Syndrome in US Children.

It is important for clinicians to recognize the contribution of toxic shock syndrome (TSS) to the overall burden of pediatric septic shock because the clinical features, optimal therapy and prognosis differ from non-TSS septic shock. We analyzed cases of pediatric septic shock reported to the Pediatric Health Information Systems database between 2009 and 2013 to define the clinical and demographic characteristics of pediatric TSS in the United States. Using a validated International Classification of Diseases, 9th revision, coding strategy, we identified patients with infectious shock among inpatients age 1-18 years and classified cases of staphylococcal and streptococcal TSS for comparison with non-TSS cases. Of 8,226 cases of pediatric septic shock, 909 (11.1%) were classified as TSS and 562 (6.8%) were possible TSS cases. Staphylococcal TSS represented the majority (83%) of TSS cases and occurred more commonly in females and at an older age. Compared with non-TSS septic shock, TSS had significantly lower fatality rates, disease severity and length of hospital stay and was present more often at the time of admission (P < 0.001 for each). Streptococcal TSS was associated with poorer outcomes than staphylococcal TSS. Treatment for TSS differed from non-TSS septic shock in use of more clindamycin, vancomycin and Intravenous Immunoglobulin and less need for vasopressors. Results demonstrate a significant contribution of TSS to the burden of pediatric septic shock in the United States. The findings emphasize the importance of inclusion of TSS diagnostic and therapeutic considerations in sepsis treatment protocols for children.

2323. Unexpected Pediatric Presentation Patterns of Toxic Shock Syndrome

BackgroundA subcategory of severe septic shock, toxic shock syndrome (TSS) represents up to 20% of pediatric septic shock in the United States. Diagnostic criteria for streptococcal TSS (STSS) and non-streptococcal TSS (NSTSS) were first published by the CDC in the early 1990s, with updates, respectively, in 2010 and 2011.MethodsThe Nationwide Children’s Hospital electronic medical record was queried for inpatient hospitalizations with ICD-9/10 codes of interest between 1/1/2010 and 8/31/2017. The query returned 579 hospitalizations which were assessed for adherence to STSS and NSTSS criteria published by the CDC. 61 cases of TSS were identified: 27 STSS, 32 NSTSS. The prevalence of organ system involvement was quantified, and organ system involvement unanticipated by CDC criteria was examined for prevalence, quality and chronology.ResultsTSS patients were predominately female (62%) with an average age of 12. The most common presentation of TSS was with hypotension (93%), fever (82%) and rash (72%). Findings unanticipated by CDC criteria include: pyuria in STSS (41%), pulmonary involvement in NSTSS (66%) and coagulation abnormalities in NSTSS (92%). Pyuria in STSS was commonly accompanied by protein (73%) and leukocyte esterase (55%) on urinalysis. Pyuria also commonly presented with hematuria (45%). Radiographic evidence of pulmonary involvement in NSTSS was typically described as bilateral/diffuse airspace disease, presenting simultaneously with pulmonary edema and pleural effusions. Abnormalities in PT/PTT associated with NSTSS were commonly found within the first few hours of admission and began normalizing by the next day; d-dimer assays were abnormal in the six instances in which they were assessed.ConclusionThis study suggests that early signs and symptoms of pediatric TSS may exist beyond those described by existing guidelines. The organ systems found to be involved in this review are often found early in the clinical course and can be assessed by noninvasive methods. Contextualization of these findings within the narrative of TSS might help clinicians better detect and diagnose a disease associated with significant patient morbidity and mortality. They may also aid in understanding the results of toxic shock surveillance efforts.Disclosures All authors: No reported disclosures.

Draft Genome Sequence of Streptococcus suis Strain SsRC-1, a Human Isolate from a Fatal Case of Toxic Shock Syndrome.

ABSTRACTStreptococcus suis is an economically important pathogen in the pig industry and is also an emerging zoonotic agent responsible for severe infections in humans. Here, we report the genome sequence of S. suis strain SsRC-1. Specifically, this strain was a serotype 2 and was isolated from a human fatal case of toxic shock syndrome (TSS) in Italy.

Clinical and Molecular Epidemiology of Staphylococcal Toxic Shock Syndrome in the United Kingdom.

Staphylococcal toxic shock syndrome (TSS) was originally described in menstruating women and linked to TSS toxin 1 (TSST-1)-producing Staphylococcus aureus. Using UK national surveillance data, we ascertained clinical, molecular and superantigenic characteristics of TSS cases. Average annual TSS incidence was 0.07/100,000 population. Patients with nonmenstrual TSS were younger than those with menstrual TSS but had the same mortality rate. Children <16 years of age accounted for 39% of TSS cases, most caused by burns and skin and soft tissue infections. Nonmenstrual TSS is now more common than menstrual TSS in the UK, although both types are strongly associated with the tst+ clonal complex (CC) 30 methicillin-sensitive S. aureus lineage, which accounted for 49.4% of all TSS and produced more TSST-1 and superantigen bioactivity than did tst+ CC30 methicillin-resistant S. aureus strains. Better understanding of this MSSA lineage and infections in children could focus interventions to prevent TSS in the future.

Left ventricular calcification following postpartum toxic shock syndrome

Toxic shock syndrome (TSS) is a rare but lethal clinical event that can occur during the postpartum period. Early recognition and intervention is critical to improve patient outcomes. This is a case of TSS complicated by cardiac arrest and left ventricular calcification. This is a case report of streptococcal TSS in a 29-year-old female in the postpartum period who presented with fever, abdominal distension, and a purpuric rash. Her hospital course was characterized by multiple organ failure, including respiratory distress syndrome, liver failure, renal failure, and coagulopathy. She was found to have acute compartment syndrome, which resulted in a below-the-knee amputation. She deteriorated further after experiencing cardiac arrest and the development of hypoxic-ischemic encephalopathy with hemorrhagic transformation. A computed tomography scan of the chest revealed evidence of dystrophic myocardial calcification in the left ventricle. She improved clinically but remained ventilator dependent upon discharge to an extended acute care facility. Sepsis-induced cardiomyopathy can result in myocardial calcification. As dystrophic calcification can significantly affect cardiac function, clinicians should rule out cardiac calcification in patients who have had severe septic shock.

Toxic shock in children with bone and joint infections: a review of seven years of patients admitted to one intensive care unit.

PurposeThe objective of this study was to compare the frequency of severe systemic, multi-organ involvement and toxic shock syndrome (TSS) in patients with Staphylococcus aureus (SA) and Group A β-haemolytic Streptococcus pyogenes (GABS) bone and joint infections.MethodsWe retrospectively reviewed patients treated for septic arthritis or osteomyelitis at one children’s hospital between 2002 and 2009. The rates of intensive care unit (ICU) admission for methicillin-sensitive SA (MSSA), methicillin-resistant SA (MRSA) and GABS infections were compared, as were the lengths of stay, number of surgeries, operative procedures and cases of TSS.ResultsA total of 16 of 208 patients (7.7%) with culture-positive bone or joint infections were admitted to the ICU for critical illness: more commonly for patients with GABS infection (7/21 or 33%) than those with SA infection (6/132 or 5%) (odds ratio 10.55, 95% confidence interval 3.093 to 35.65, p = 0.0002). Patients with MRSA infections were significantly more likely to need ICU care than those with MSSA infection (p = 0.0009). Six of the ICU patients met the Centers for Disease Control and Prevention criteria for TSS. ICU patients with MRSA and GABS bone and joint infections had similar hospital courses: numerous surgeries (mean three per patient); procedures performed (mean 11 per patient); and prolonged hospital stays.ConclusionWe found a greater likelihood of patients developing severe, multi-system involvement with bone and joint infections caused by GABS or MRSA when compared with MSSA. Early aggressive treatment of systemic shock and liberal decompressions of infected joints may limit the sequelae of these serious infections.

Intense, flu-like symptoms in women using menstrual devices: always think of staphylococcal Toxic Shock Syndrome

[This corrects the article DOI: 10.1093/omcr/omx020.].

A case of toxic shock syndrome after cesarean section

A case of toxic shock syndrome after cesarean section

Toxic Shock Syndrome following Tattooing

Toxic shock syndrome (TSS) is a rare but life-threatening illness that is mainly caused by toxigenic strains of Staphylococcus aureus. Although TSS is classically known to be associated with tampon use, the number of TSS cases with non-menstrual causes such as skin and soft tissue infection has been increasing. Tattooing can result in several complications such as localized and systemic infections, inflammatory skin eruptions and neoplasms. We recently experienced a 26-year-old man diagnosed with typical TSS following tattooing. He complained of fever, chills and erythematous rash at tattoo site. Subsequently, the patient developed sign of shock. The skin cultures on the tattoo site were positive for methicillin-sensitive Staphylococcus aureus. The patient was successfully treated with vasopressor infusion and intravenous antibiotics and was discharged without complications. On discharge from the hospital 7 days later, desquamations on the tattoo site, fingers and toes were observed.

Staphylococcal toxic shock syndrome due to umbilical piercing

Staphylococcus aureus is a ubiquitous pathogen responsible for a wide range of pathology, including toxic shock syndrome (TSS). We report a rare case of TSS in an otherwise healthy 16-year-old female with recent history of cellulitis at the site of umbilical piercing. The described case is an important reminder for physicians to consider TSS in the differential diagnosis of septic-appearing patients, including those with history of cutaneous infections near body piercing sites.

Kirschner wire infections in pediatric orthopaedic surgery.

Few studies have described the presentation, bacteriology, risk factors, and complications of Kirschner wire infections in pediatrics. The purpose of this study is to describe these factors to better understand, prevent, and treat infectious complications of smooth wires. A retrospective review was performed to identify all patients (birth to 16 y) who were hospitalized for Kirschner wire infection from 1995 to 2012. Presentation, hospital course, bacteriology, outcomes, and complications were recorded. A management algorithm was developed from the experience. Kirschner wire infections were present in 12 patients: 5 supracondylar fractures, 3 lateral humeral condylar fractures, a distal tibia physeal fracture, a great toe open fracture, a distal radius fracture, and an elective osteotomy for hallux valgus. The patients presented with cellulitis in 3 cases, soft-tissue abscess in 4 cases, osteomyelitis in 4 cases, and 1 case of toxic shock syndrome. A history of missed appointments or wet dressing was present in 60% of cases. Reoperation was required in 5 patients with abscess, septic arthritis, or osteomyelitis. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common pathogen followed by Pseudomonas aeruginosa. Methicillin-resistant S. aureus was not seen. Complications were present in 5 patients and included: loss of range of motion, joint destruction, wound breakdown, catheter migration, and toxic shock syndrome. Infected Kirschner wires are rare and may be maintained in a nonunited bone if the infection is superficial. Infections in this series commonly had a history of missed appointments and wet dressings, which suggests that improved postoperative education may reduce the risk. Osteomyelitis was often preceded by pin-site drainage and failed oral antibiotic therapy. MSSA and Pseudomonas were most commonly cultured and should be considered when empiric antibiotic therapy is necessary. Prognostic level IV.

Recurrent Menstrual Toxic Shock Syndrome With and Without Tampons in an Adolescent

Recurrent Menstrual Toxic Shock Syndrome With and Without Tampons in an Adolescent

Increased prevalence of group A streptococcus isolates in streptococcal toxic shock syndrome cases in Japan from 2010 to 2012.

Streptococcal toxic shock syndrome (STSS) is a severe invasive infection characterized by the sudden onset of shock, multi-organ failure, and high mortality. In Japan, appropriate notification measures based on the Infectious Disease Control law are mandatory for cases of STSS caused by β-haemolytic streptococcus. STSS is mainly caused by group A streptococcus (GAS). Although an average of 60-70 cases of GAS-induced STSS are reported annually, 143 cases were recorded in 2011. To determine the reason behind this marked increase, we characterized the emm genotype of 249 GAS isolates from STSS patients in Japan from 2010 to 2012 and performed antimicrobial susceptibility testing. The predominant genotype was found to be emm1, followed by emm89, emm12, emm28, emm3, and emm90. These six genotypes constituted more than 90% of the STSS isolates. The number of emm1, emm89, emm12, and emm28 isolates increased concomitantly with the increase in the total number of STSS cases. In particular, the number of mefA-positive emm1 isolates has escalated since 2011. Thus, the increase in the incidence of STSS can be attributed to an increase in the number of cases associated with specific genotypes.

Staphylococcal toxic shock syndrome: superantigen-mediated enhancement of endotoxin shock and adaptive immune suppression.

Infectious diseases caused by Staphylococcus aureus present a significant clinical and public health problem. S. aureus causes some of the most severe hospital-associated and community-acquired illnesses. Specifically, it is the leading cause of infective endocarditis and osteomyelitis, and the second leading cause of sepsis in the USA. While pathogenesis of S. aureus infections is at the center of current research, many questions remain about the mechanisms underlying staphylococcal toxic shock syndrome (TSS) and associated adaptive immune suppression. Both conditions are mediated by staphylococcal superantigens (SAgs)-secreted staphylococcal toxins that are major S. aureus virulence factors. Toxic shock syndrome toxin-1 (TSST-1) is the SAg responsible for almost all menstrual TSS cases in the USA. TSST-1, staphylococcal enterotoxin B and C are also responsible for most cases of non-menstrual TSS. While SAgs mediate all of the hallmark features of TSS, such as fever, rash, hypotension, and multi-organ dysfunction, they are also capable of enhancing the toxic effects of endogenous endotoxin. This interaction appears to be critical in mediating the severity of TSS and related mortality. In addition, interaction between SAgs and the host immune system has been recognized to result in a unique form of adaptive immune suppression, contributing to poor outcomes of S. aureus infections. Utilizing rabbit models of S. aureus infective endocarditis, pneumonia and sepsis, and molecular genetics techniques, we aim to elucidate the mechanisms of SAg and endotoxin synergism in the pathogenesis of TSS, and examine the cellular and molecular mechanisms underlying SAg-mediated immune dysfunction.

Toxic shock syndrome following inguinal hernia repair: a rare condition

A 25-year-old man developed fulminant multisystem failure 28 hours after elective repair of an inguinal hernia. Toxic shock syndrome (TSS) was diagnosed. The patient recovered fully with supportive care in ICU, antibiotics, and IV human immunoglobin . To the best of our knowledge, only one case of TSS following inguinal hernia repair have ever been previously published. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-2, 57-59 DOI: http://dx.doi.org/10.3126/jcmsn.v9i2.9689

肝門部胆管癌術後に発症した皮膚症状を伴わないToxic Shock Syndromeの１例

肝門部胆管癌術後に発症した皮膚症状を伴わないToxic Shock Syndrome（以下，TSSと略記）の１例を報告する．69歳男性で，肝門部胆管癌と閉塞性黄疸で紹介された．PTBDによる減黄後，肝門部胆管切除術，拡大肝右葉切除，尾状葉合併切除術を施行した．第４病日に大量膿性腹水認め，全身状態が悪化した．血液と腹水培養からMRSAが検出され，MRSA腹腔内感染と診断された．集学的治療を行うも，肝梗塞を併発し第13病日に死亡した．MRSA菌株解析によりTSS toxin-1（以下，TSST-1と略記）産生株と判明した．本例は典型的な皮膚症状がなかったものの，皮膚症状以外でTSS診断基準を満たし，TSST-1産生MRSAが起因菌であったため，TSSと診断した．過大侵襲を伴う手術の場合，TSSは治療の遅れにより致命的な転帰となりうる．早期診断と抗MRSA薬と免疫グロブリンによる治療が必須である．

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

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.

Expression of toxic shock syndrome toxin-1 by epidemic meticillin-resistant Staphylococcus aureus 16

BackgroundStaphylococcal toxic shock syndrome (TSS) is a fatal illness attributed to Staphylococcus aureus toxic shock syndrome toxin-1 (TSST-1), encoded by the tst gene. No epidemiological data on TSS exist from the UK. Strains of S aureus may carry the tst gene but not cause TSS, such as the UK strain epidemic meticillin-resistant SA-16 (EMRSA-16). The aim of this study was to determine the epidemiology of TSS in the UK and investigate the expression of TSST-1 by EMRSA-16 and tst+ meticillin-sensitive S aureus (MSSA). MethodsCases of TSS were identified at the UK Health Protection Agency (HPA) and epidemiological features analysed. A selection of clonal complex (CC)-30 EMRSA-16 and TSS-associated MSSA strains was chosen for investigation. The tst gene and promoter region were sequenced in all strains. The staphylococcal pathogenicity island (SaPI) harbouring tst was determined by PCR. Growth of strains in brain heart infusion broth was monitored by optical density (OD600). TSST-1 in supernatants was quantified by western blot using densitometry according to a TSST-1 standard curve. RNA was isolated for tst transcript analysis by quantitative reverse-transcription-PCR (qRT-PCR). Whole genome sequencing was performed on all strains to identify potential mutations in known regulators of toxin synthesis. Findings150 cases of TSS were reported to the HPA over a period of 4 years. Six cases (4%) were attributable to MRSA and the remainder to MSSA. There was no difference in the tst gene or promoter sequence among the strains and tst was carried by SaPI2. TSST-1 production by EMRSA-16 strains commenced earlier in growth than did MSSA strains and was greater in TSS-associated MSSA than in EMRSA-16 strains throughout growth. These results were compared with tst transcription by MSSA and EMRSA16 using qRT-PCR. InterpretationEMRSA-16 produces less TSST-1 than does MSSA of the same lineage; this may be due to differences in global gene regulators, perhaps as a result of changes in PBP2a expression, or the carriage of a large SCCmec element by EMRSA-16. This difference in production may explain the paucity of TSS cases caused by MRSA. FundingUK National Centre for Infection Prevention and Management.

A case report of toxic shock syndrome in a patient with underlying chronic liver disease associated with multiple satellite abscesses in elbow, perinephric region, psoas, and neck

Toxic shock syndrome is an acute febrile illness, which leads to multi-organ dysfunction and has a high mortality and morbidity. We report a case of toxic shock syndrome in a patient with underlying chronic liver disease associated with multiple satellite abscesses in elbow, peri-nephric region, psoas and neck.