(638) A Case of Staphylococcal Toxic Shock Syndrome From a Skin and Soft Tissue Infection

Introduction: Staphylococcal toxic shock syndrome (STSS) is a rapidly progressive systemic illness caused by toxin-producing strains of Staphylococcus aureus. Toxic shock syndrome toxin-1 (TSST-1) acts as a superantigen, initiating T cell activation and proliferation three thousand times more than conventional antigens leading to rapid clinical deterioration through uncontrolled neutrophil activation, fibrinolysis, and nitric oxide release. Historically attributed to tampon usage, skin and soft tissue infections have emerged as the leading nidus for STSS as described in the following case.

Description: This is a case of a 28-year-old healthy female who presented to the hospital with nausea, vomiting, diarrhea, headache, pyrexia, and rash. She received a tattoo on her left calf six days prior to admission before driving from Colorado to Michigan with stops in Nebraska and Illinois. Vomiting began within hours of eating beef at a food truck. The following day she noticed diarrhea and a well-demarcated erythematous crusting exanthem along the tattoo border. The night prior to admission she had pyrexia up to 102o F, malaise, and vomiting prompting her presentation. The patient was initially stable apart from tachycardia. Pertinent exam findings included diffuse erythroderma, tattoo-related peeling of the skin with a raised golden-crusted erythematous rash and cellulitic extension to the thigh. Labs were remarkable for transaminitis, hyperbilirubinemia, renal dysfunction, elevated creatine kinase, hypocalcemia, leukocytosis, and thrombocytopenia. Initial treatment included vancomycin, meropenem, clindamycin, doxycycline, and fluid resuscitation. Cultures grew methicillin-sensitive S. aureus. She improved clinically and was discharged on day 5 with oral cephalexin for a total of 10 days of therapy.

Discussion: This case represents the widespread effects of STSS and the presence of skin and soft tissue infections as the primary nidus. Furthermore, it highlights a wide array of differentials including Rocky Mountain spotted fever, hemolytic uremic syndrome and thrombotic thrombocytopenic purpura which present with significant overlap of physical and laboratory findings. This case illustrates the importance of a thorough history and physical examination in the accurate diagnosis of complex patients.