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A Case of Toxic Shock?. Edward L. Goodman, MD September 18, 2002. Outline. Case Presentation Relevant Epidemiology Differential Diagnosis Pathophysiology Management. Case Presentation. July 18, 2002 CC: SOB, Hypotension, Dizzy

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a case of toxic shock

A Case of Toxic Shock?

Edward L. Goodman, MD

September 18, 2002

outline
Outline
  • Case Presentation
    • Relevant Epidemiology
  • Differential Diagnosis
  • Pathophysiology
  • Management
case presentation
Case Presentation
  • July 18, 2002
  • CC: SOB, Hypotension, Dizzy
  • HPI: 74 WM two day hx of chills, fever, SOB and weakness. Tender in right thigh
    • GERD surgery 5/6/02 complicated by necrotizing pancreatitis and open wound after laparotomy
    • Wound Care Department managing open wound as outpatient
history 2
History 2
  • PMH
    • IDDM
    • HBP
    • PUD
    • Hyperlipidemia,
    • Diverticulosis
    • Prostate Ca S/P XRT and Lupron
slide5
Exam
  • Alert but confused
  • BP 80’s, tachycardia
  • Healing open abdominal wound
  • Faint, generalized erythema
  • Tender demarcated erythema swollen right thigh
  • Tinea pedis
epidemiology
Epidemiology
  • 2001 Outbreak Group A Streptococcal infections of complex wounds
    • 28 cases/10 isolates were available and typed
    • Epidemic strain identified
      • Identical emm (M protein) type
      • Levofloxacin/clindamycin resistant
        • Virtually all patients had been on these drugs
    • 52 control patients selected to compare with 10 cases
epidemiology continued
Epidemiology - continued
  • Multivariate analysis
    • No relationship to sex, type of wound or underlying condition
    • Age >60 related
  • Thus, strong link to exposure to a specific group of HCW
  • Subsequent extensive HCW cultures negative
    • Implicated group
    • Many others
  • Epidemic ceased July 2001
epidemiology continued1
Epidemiology - continued
  • July 12, 2002 first case of GAS infection of a complex wound in 12 months
    • Four suspected HCW cultured again
    • One grew GAS from two sites - asymptomatic
    • One environmental isolate positive
    • All four isolates were identical but different M type from 2001 strain
  • Our patient was exposed to the implicated HCW!
initial therapy
Initial Therapy
  • Received Cefotaxime by ER staff
  • Admitting Team started IV Pen G and Clindamycin
  • IVIG daily x 5 days
  • Vigorous support
  • Surgery consulted early and often
    • No surgery required!
discussion
Discussion
  • Was there reason to infer a GAS etiology?
    • Clinical appearance
    • Relevant epidemiology
    • (No cultures were positive for GAS)
    • Strongly positive anti DNAse B suggests recent or current infection
  • Did he have invasive GAS infection?
  • Did he have features of GAS TSS?
    • See Case Definition
discussion1
Discussion
  • Antibiotics
    • Penicillin
    • Clindamycin
  • Role of IVIG
penicillin s ineffectiveness
Penicillin’s ineffectiveness
  • High mortality in invasive GAS when Penicillin used
    • 81% mortality in myositis
    • Animal data on inoculum effect
  • High concentrations of GAS in deep sites
    • Stationary phase reached quickly
    • PBPs not expressed in stationary phase
clindamycin
Clindamycin
  • No inoculum effect
  • Suppresses toxin synthesis
  • Facilitates phagocytosis by inhibiting M protein synthesis
  • Suppresses proteins involved in cell wall synthesis
  • Longer post antibiotic effect (PAE)
  • Suppress LPS induced monocyte synthesis of TNF-alpha
tss and ivig
TSS and IVIG
  • Shock from gram positive toxins
    • Superantigens
      • Enterotoxins
      • TSST-1
      • SPEA
    • Superantigens bind to
      • MHC II
      • ß chain of T cell receptor
    • Resulting in
      • T cell proliferation
      • Cytokine production
slide28
IVIG
  • Blocks in vitro T cell activation
  • Contains superantigen neutralizing antibodies
conclusion
Conclusion
  • Severe pain and fever – think of GAS
  • Know the epidemiology of your institution
  • Consult a surgeon promptly
  • Add Clindamycin to beta lactam therapy for necrotizing or serious GAS infections
  • Consider IVIG for TSS
references
References
  • Bisno AL, Stevens DL. Streptococcal Infections of Skin and Soft Tissues. New Eng J Med 1996; 334:240-245.
  • Case Records of the MGH. New Eng J Med 1995; 333: 113-119.
  • Case Records of the MGH. New Eng J Med 2002; 347:831-837.
  • Disease Prevention News. TDH. March 27, 2000;60: No.7.
  • Kaul R, McGeer A et al. Intravenous Immunoglobulin Therapy for Streptococcal Toxic Shock Syndrome – A Comparative Observational Study. Clin Infect Dis 1999; 28:800-807.
references continued
References - continued
  • Kazatchkine MD, Kaveri, SV. Immunomodulation of Autoimmune and Inflammatory Diseases with Intravenous Immune Globulin. New Eng J Med 2001; 345: 747-755.
  • Stevens DL. The Flesh-Eating Bacterium: What’s Next. J Infect Dis 1999;179(Suppl 2): S366-374
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