A 20-year-old college student is brought to the emergency department due to progressive lethargy and confusion. He is obtunded and unable to answer questions, but his friend says the patient has had shaking chills and diarrhea since last night. He has no prior medical problems other than a nasal fracture following a bar fight 3 days ago, which was reduced and stabilized with nasal packing at another hospital. The patient takes no medications and has no known drug allergies. He lives in a dormitory and recently returned from a hiking trip in North Carolina.
Temperature is 39.4 C (103 F), blood pressure is 84/42 mm Hg, pulse is 126/min, and respirations are 18/min. Examination shows an ill-appearing man. Pupils are equal, round, and reactive. Anterior packing is present in the left nostril. There is diffuse erythema of the mucous membranes and skin, including the palms and soles. Mild pitting edema is present in both legs.
Laboratory results are as follows:
CT scan of the head reveals no abnormalities. Venous access is established, and intravenous fluids are administered.
Which of the following is the most appropriate antimicrobial therapy for this patient?

Question

A 20-year-old college student is brought to the emergency department due to progressive lethargy and confusion.  He is obtunded and unable to answer questions, but his friend says the patient has had shaking chills and diarrhea since last night.  He has no prior medical problems other than a nasal fracture following a bar fight 3 days ago, which was reduced and stabilized with nasal packing at another hospital.  The patient takes no medications and has no known drug allergies.  He lives in a dormitory and recently returned from a hiking trip in North Carolina.
Temperature is 39.4 C (103 F), blood pressure is 84/42 mm Hg, pulse is 126/min, and respirations are 18/min.  Examination shows an ill-appearing man.  Pupils are equal, round, and reactive.  Anterior packing is present in the left nostril.  There is diffuse erythema of the mucous membranes and skin, including the palms and soles.  Mild pitting edema is present in both legs.
Laboratory results are as follows:
 CT scan of the head reveals no abnormalities.  Venous access is established, and intravenous fluids are administered.
Which of the following is the most appropriate antimicrobial therapy for this patient?

Quizplus · Accepted Answer

11ec193a_963d_25cb_853d_970d494067cc_MD0002_00 This patient who had nasal packing 3 days ago now has manifestations of toxic shock syndrome (TSS). TSS is usually caused by a powerful Staphylococcus aureus exotoxin, which acts as a superantigen and results in the widespread activation of T cells, leading to a massive inflammatory response. Most cases are associated with menstrual tampons, nasal packing, or surgical/postpartum wound infections. Staphylococcal TSS is marked by rapid-onset fever (>38.9 C [102 F]), hypotension, diffuse erythroderma, desquamating rash, and multiorgan failure. Encephalopathy can occur secondary to cerebral edema. S aureus can usually be isolated from the infection source, but blood cultures are rarely (<5%) positive. Management is focused on supportive therapy, removal of the foreign material (eg, nasal packing, tampon) or surgery (eg, wound infections), and the initiation of antistaphylococcal antibiotics. Clindamycin and vancomycin are used most commonly; clindamycin is highly effective at inhibiting toxin production. Eradication of S aureus from the nares with mupirocin may be considered after recovery. TSS can also be caused by group A streptococcus, but patients typically have a painful skin infection and are less likely to develop erythroderma. (Choice A) Meningococcemia can cause rapid-onset fever, altered mental status, hypotension, and rash. However, petechial rash (not erythroderma) is the norm, and patients also frequently have myalgias, meningeal signs, and headache. Suspected cases are usually treated empirically with ceftriaxone and vancomycin. (Choice B) Rocky Mountain spotted fever is a tick-borne illness that usually begins with nonspecific systemic symptoms followed 3-5 days later by a maculopapular/petechial rash (starts on ankles/wrists and spreads centrally and to the palms/soles). Early treatment with doxycycline is required to prevent morbidity and death. (Choice C) Secondary syphilis is treated with penicillin G. Although secondary syphilis can cause a diffuse maculopapular rash, it is unlikely to cause rapid decompensation with hypotension. (Choice D) Vancomycin and cefepime would be indicated if this patient suffered a basal skull fracture during his fight and developed meningitis. Although he does have high fever and altered mental status, the presence of nasal packing, erythroderma, and multiorgan failure makes TSS more likely. Educational objective: Staphylococcal toxic shock syndrome (TSS) must be considered in patients with abrupt onset of fever, hypotension, and diffuse erythroderma. Most cases occur in the setting of menstrual tampons, nasal packing, or surgical/postpartum wound infections. Treatment involves supportive care, removing the foreign material (or surgery), and broad-spectrum antistaphylococcal antibiotics (eg, clindamycin and vancomycin). __________ References: Gram-positive toxic shock syndromes. (http://www.ncbi.nlm.nih.gov/pubmed/19393958) Staphylococcal toxic shock syndrome 2000-2006: epidemiology, clinical features, and molecular characteristics. (http://www.ncbi.nlm.nih.gov/pubmed/21860665)

A 20-Year-Old College Student Is Brought to the Emergency Department