A 25-year-old man is brought to the emergency department due to high-grade fever, chills, myalgias, and skin rash, which started on the day of admission. He also had nausea and 3 episodes of profuse watery diarrhea and is now feeling lightheaded. Two days ago, he underwent corrective surgery for a deviated nasal septum but otherwise has no other past medical history. The patient has not traveled recently and has not been around sick contacts. He does not use illicit drugs. His temperature is 39.4 C (103 F), blood pressure is 85/50 mm Hg, and pulse is 116/min. Oxygen saturation is 98% on room air. He is lethargic but has no focal weakness or nuchal rigidity. Examination shows clear lung fields and tachycardia with normal first and second heart sounds. The abdomen is soft and nontender. There is nasal packing in both nostrils. Skin examination shows a diffuse, red, macular rash that also involves the palms and soles. Blood cultures are sent. Which of the following is the most important next step in the treatment of this patient?

Question

A 25-year-old man is brought to the emergency department due to high-grade fever, chills, myalgias, and skin rash, which started on the day of admission.  He also had nausea and 3 episodes of profuse watery diarrhea and is now feeling lightheaded.  Two days ago, he underwent corrective surgery for a deviated nasal septum but otherwise has no other past medical history.  The patient has not traveled recently and has not been around sick contacts.  He does not use illicit drugs.  His temperature is 39.4 C (103 F), blood pressure is 85/50 mm Hg, and pulse is 116/min.  Oxygen saturation is 98% on room air.  He is lethargic but has no focal weakness or nuchal rigidity.  Examination shows clear lung fields and tachycardia with normal first and second heart sounds.  The abdomen is soft and nontender.  There is nasal packing in both nostrils.  Skin examination shows a diffuse, red, macular rash that also involves the palms and soles.  Blood cultures are sent. Which of the following is the most important next step in the treatment of this patient?

Quizplus · Accepted Answer

Explanation: Patients with symptoms suggestive of toxic shock syndrome (TSS) should be carefully examined for any potentially associated foreign bodies (eg, nasal packing), which should be removed. They may require extensive fluid replacement, which can reach 20 L per day. Physicians generally administer clindamycin (which theoretically prevents toxin synthesis) with or without antistaphylococcal antimicrobial therapy (vancomycin, or oxacillin or nafcillin if susceptible) to eradicate the organism and prevent TSS recurrence. Corticosteroids do not seem to affect mortality and are not routinely recommended (Choice D). (Choice A) If hypotension persists despite fluid resuscitation, vasopressors agents may also be needed in the intensive care unit; dobutamine is usually reserved for cardiogenic shock. (Choice B) Epinephrine and antihistamines are used in the management of allergic reactions leading to anaphylactic shock. Antihistamines are not likely to help with TSS. (Choice E) Polyclonal human immunoglobulin has not been extensively assessed for the treatment of TSS and appears to be more effective in streptococcal rather than staphylococcal TSS. It can be considered in severe cases (eg, patients unresponsive to fluids and pressors). Educational objective: The mainstay of treatment for toxic shock syndrome is supportive therapy. Patients may require extensive fluid replacement that can reach 20 L per day.

A 25-Year-Old Man Is Brought to the Emergency Department Due