A 21-year-old woman is brought to the emergency department due to continuous vomiting, diarrhea, and high fever for a day. The patient also has a severe headache that is unrelieved by acetaminophen. She has no hematemesis or hematochezia. The patient spent the last 3 months in Southeast Asia and returned yesterday on an international flight. She has no chronic medical conditions or previous surgeries. The patient does not use tobacco or illicit drugs. She is currently on the fifth day of her menstrual period and has had to use both tampons and pads due to heavy bleeding. Temperature is 39.4 C (103 F), blood pressure is 80/40 mm Hg, and pulse is 124/min. Physical examination reveals a diaphoretic woman with dry mucous membranes. There is no nuchal rigidity. An erythematous macular rash covers the entire body, including the palms and soles. Which of the following microorganisms is most likely responsible for this patient's symptoms?

Question

A 21-year-old woman is brought to the emergency department due to continuous vomiting, diarrhea, and high fever for a day.  The patient also has a severe headache that is unrelieved by acetaminophen.  She has no hematemesis or hematochezia.  The patient spent the last 3 months in Southeast Asia and returned yesterday on an international flight.  She has no chronic medical conditions or previous surgeries.  The patient does not use tobacco or illicit drugs.  She is currently on the fifth day of her menstrual period and has had to use both tampons and pads due to heavy bleeding.  Temperature is 39.4 C (103 F), blood pressure is 80/40 mm Hg, and pulse is 124/min.  Physical examination reveals a diaphoretic woman with dry mucous membranes.  There is no nuchal rigidity.  An erythematous macular rash covers the entire body, including the palms and soles.  Which of the following microorganisms is most likely responsible for this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d9e3_bb24_bc81_d561c9ce929f_MD0003_00 This patient has toxic shock syndrome (TSS), which typically presents with high fever, hypotension, tachycardia, and a diffuse, red, macular rash involving the palms and soles. Other clinical manifestations of TSS may include headache, vomiting, profuse diarrhea, and mucous membrane hyperemia or ulceration. Desquamation of the palms and soles occurs 1-3 weeks after disease onset. Menstrual cases of TSS are caused by Staphylococcus aureus infection related to prolonged or continuous tampon use, as in this patient. Disease occurs due to the release of toxic shock syndrome toxin-1, an exotoxin that acts as a superantigen and causes an exaggerated immune response leading to shock (eg, hypotension, tachycardia) and multiorgan failure (eg, decreased urine output, altered mentation). The diagnosis is made clinically. Treatment includes massive fluid replacement, antibiotic therapy, and removal of the foreign body (eg, tampon). (Choice A) Disseminated gonococcal infection, caused by Neisseria gonorrhoeae, can present with a pustular, rather than macular, dermatitis. Tenosynovitis and an asymmetric, migratory polyarthralgia are also typically present, but not acute hypotension and tachycardia (ie, shock). (Choice B) Rotavirus (eg, travelers' diarrhea) causes a mild gastroenteritis in adults and may present with watery diarrhea and dry mucous membranes; however, rotavirus does not cause rash, making this diagnosis unlikely. (Choice C) Shigella gastroenteritis causes fever, bloody diarrhea, and abdominal cramping but not rash. (Choice E) Secondary syphilis, caused by Treponema pallidum, can present with a maculopapular rash involving the hands and soles. Patients may also develop a low fever, malaise, and epitrochlear adenopathy. However, patients typically have an indolent course rather than acute-onset hypotension and tachycardia (ie, shock). Educational objective: Toxic shock syndrome, due to Staphylococcus aureus bacteremia and associated exotoxin release, presents with fever, hypotension, tachycardia, and a diffuse, red, macular rash involving the palms and soles. Treatment includes fluid replacement, antibiotic therapy, and removal of the foreign body. References: Lesson of the month 2: toxic shock syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/24889583) Toxic shock syndrome - the seven Rs of management and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28646955)

A 21-Year-Old Woman Is Brought to the Emergency Department Due