An 18-year-old woman is brought to the emergency department with severe vomiting, diarrhea, and dizziness that started this morning. Three days ago, she had nasal bleeding that required anterior packing in the emergency department. Yesterday, she had pain and a sensation of pressure under her left eye and scant blood-tinged nasal discharge. The pain was relieved by acetaminophen and ibuprofen. The patient, who has no sick contacts, has a history of asthma and allergic rhinitis. Her last menstrual period was 3 weeks ago. She does not use tobacco, alcohol, or illicit drugs. Her temperature is 38.9° C (102.2° F), blood pressure is 90/60 mm Hg supine and 66/45 mm Hg standing, pulse is 120/min, and respirations are 23/min. She appears alert but restless. On examination, there are diffuse, confluent erythematous macules on her trunk and extremities. The oropharynx appears hyperemic. Laboratory results are as follows:
Which of the following is the most likely diagnosis?

Question

An 18-year-old woman is brought to the emergency department with severe vomiting, diarrhea, and dizziness that started this morning.  Three days ago, she had nasal bleeding that required anterior packing in the emergency department.  Yesterday, she had pain and a sensation of pressure under her left eye and scant blood-tinged nasal discharge.  The pain was relieved by acetaminophen and ibuprofen.  The patient, who has no sick contacts, has a history of asthma and allergic rhinitis.  Her last menstrual period was 3 weeks ago.  She does not use tobacco, alcohol, or illicit drugs.  Her temperature is 38.9° C (102.2° F), blood pressure is 90/60 mm Hg supine and 66/45 mm Hg standing, pulse is 120/min, and respirations are 23/min.  She appears alert but restless.  On examination, there are diffuse, confluent erythematous macules on her trunk and extremities.  The oropharynx appears hyperemic. Laboratory results are as follows:
 Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d927_21a8_bc81_fdc06784402a_MD0003_00 This patient's clinical presentation (recent nasal packing followed by rapid onset of rash, fever, hypotension, diarrhea, and thrombocytopenia) is consistent with toxic shock syndrome (TSS) due to Staphylococcus aureus. TSS is caused by toxic shock syndrome toxin-1, which acts as a superantigen and causes T cell activation and release of large amounts of cytokines. Approximately 50% of TSS cases are related to menstruation (tampon use); the remainder are nonmenstrual (eg, surgical wound infections, sinusitis, septorhinoplasty). The clinical symptoms and signs of TSS develop rapidly, and the median interval after onset of menstruation (or infections) is 2-3 days. Signs and symptoms include fever, diffuse myalgias, vomiting, profuse diarrhea, hypotension, and a diffuse macular erythroderma similar to sunburn. Leukocytosis may not be present, but immature neutrophils are elevated. Thrombocytopenia is common instead. Management includes supportive therapy (eg, intravenous fluids), removal of foreign materials from surgery, and broad-spectrum anti-staphylococcal antibiotics. (Choice A) Skin findings in acute meningococcemia include a petechial rash that progresses to ecchymosis, bullae, vesicles, and, ultimately, gangrenous necrosis. Patients also usually present with fever, nausea, vomiting, severe myalgias, meningeal signs, and shock. (Choice B) The rash associated with Rocky Mountain spotted fever is typically petechial, starts in the extremities, and usually occurs a few days after fever onset. This patient's recent nasal packing makes TSS much more likely. (Choice C) Scarlet fever is primarily a disease of children. Typically, a group A streptococcal infection occurs earlier at another site (eg, tonsillitis, pharyngitis). Skin findings are typically preceded by a prodrome of fever, headache, vomiting, and sore throat. Twelve to 48 hours later, fine pink blanching papules appear on the neck and upper trunk and quickly generalize with flexural accentuation (rough, sandpaper-like texture). (Choice D) Stevens-Johnson syndrome is a severe skin reaction to certain medications and is occasionally due to infections in children. It is characterized by a prodrome of fever and influenza-like symptoms, followed by the development of mucocutaneous erythematous and purpuric macules that progress to necrosis and sloughing of the epidermis. This patient's overall presentation is more consistent with TSS (eg, nasal packing, nasal discharge, marked hypotension). Educational objective: Toxic shock syndrome due to Staphylococcus aureus is associated with menstruation (tampons), nasal packing, and post-surgery infections. Patients usually develop fever, myalgias, marked hypotension, and diffuse erythematous macular rash (erythroderma) that can progress to multiorgan involvement. References: Toxic-shock syndrome associated with nasal packing: analogy to tampon-associated illness. (http://www.ncbi.nlm.nih.gov/pubmed/6694872) Gram-positive toxic shock syndromes. (http://www.ncbi.nlm.nih.gov/pubmed/19393958) Characterization of three Staphylococcus aureus isolates from a 17-year-old female who died of tampon-related toxic shock syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20351214)

An 18-Year-Old Woman Is Brought to the Emergency Department with Severe