1 / 42

CASE PRESENTATION ``Heroes``

CASE PRESENTATION ``Heroes``. Isabel Alonzo-Proulx, CCFP(EM). Case . 19 y.o.,female c/o diarrhea and vomiting Sudden onset, profuse for last 8-10 hrs Some diffuse abdo pain Presents to ED in evening: BP 100/65 P 95 T 37.8b Looks anxious,feels weak, has been tolerating PO for last hour.

niveditha
Download Presentation

CASE PRESENTATION ``Heroes``

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CASE PRESENTATION``Heroes`` Isabel Alonzo-Proulx, CCFP(EM)

  2. Case • 19 y.o.,female • c/o diarrhea and vomiting • Sudden onset, profuse for last 8-10 hrs • Some diffuse abdo pain • Presents to ED in evening: • BP 100/65 P 95 T 37.8b • Looks anxious,feels weak, has been tolerating PO for last hour

  3. Case cont... • HPI: • Ø prodrome • Ø antibiotics in last 6 months • Ø pregnant: started n menses 3 days ago • Travel: came back from Costa Rica 3 weeks ago, lived in families, has not been sick since • PMHx: • Ø previous Sx • Never pregnant

  4. Case cont... • O/E: • Mucous are dry • CV n • Pneumo n • Abdomen: slightly distended, BS+, diffuse tenderness, no guarding, no rebound CVA equivocal bilat • Skin n

  5. Case cont... • Staff comes in... • Looks sick • Asks for rectal T: 40 • Orders: • IV: 1L NS bolus • CBC, SMA-7, LFT’s, blood cultures X2 • U/A and culture • B-HCG • Stool cultures x2, parasites, and C.Diff

  6. Case cont... • Results: • WBC 13 500 • U/A : RBC ++++, 1-5 leukos • Creat 86 • Hb 139 • Platelets 190 • Urinary B-HCG -

  7. Case cont... • Dx Pyelonephritis? • Started on Cipro • Observed in ER • 4 hrs later, weakness and syncope • BP: 90/40, obtunded • Non-pitting edema of face and neck • Sent to ressuc • Volume ressucitated

  8. Case cont... • Hypothesis? • DDX ?

  9. Case cont... • LABs repeated: • Creat 86, now 100 • Hb 139 now 90 • Platelets 190 now 100 • U/S abdomen and pelvis: • splenomegalia 16 cm • mesenteric adenitis • n otherwise

  10. Case cont... • DDx: • Acute pyelonephritis? • Septic shock? • PID? • HUS? • Leptospirosis? • Gastroenteritis? • Tick Typhus?

  11. And now... • Pt develops a rash:

  12. Case cont... • DDX : • Kawasaki disease? • Reye syndrome? • Erythema multiforma? • Rocky Mountain spotted fever?

  13. Staphyloccocal Toxic Shock Syndrome Staph TSS

  14. Staphylococcus • Gram positive cocci:

  15. S.Aureus - Pathologies • Local invasion and tissular destruction: • Impetigo • Cellulitis • Endocarditis • ... • Toxin mediated • TSS • Staphyloccocal exfoliation syndrome • Food poisoning

  16. S. Aureus - Epidemiology • Reservoir – Human • Asymptomatic carriers: • Naso-pharynx • Rectum • Perineum: 98% of women w TSS compared w control subjects • Cutaneous colonisation – brief, repetitive • Transmission – person to person

  17. Population General population HD patients DB insulin Desensitivation therapy patients IV drug users Carrier rate (%) 25 75 50 50 40 S. Aureus – Carrier rate

  18. STSS - Historical 1978 – Todd and Fishaut first describe STSS • Acute febrile illness in 7 children • Development of shock • Association w staphylococcus aureus 1981 –US epidemic • TSS identified in 941 pts • 812 menstrual cases; otherwise healthy women • Association w hyperabsorbant tampons use Drastic drop in incidence since 1980 Now 50% of case are nonmentrual

  19. Therapeutic Product Directorate: TPD-Web Toxic shock syndrome and tampons : the risk remains • US: annual incidence STSS: • 1-5 cases per 100 000 women in menstruation • > 90% in female 15-19y • Mortality 3.3%

  20. STSS – Risk factors • Menses • Tampons : increased risk 33 times in susceptible women • Nasal packing • Young age • Previous STSS • Vaginal – postpartum or following abortion • Surgical wounds: hernia repair, mammoplasty, arthroscopy • Septorhinoplasty • Influenza or influenza-like illness

  21. STSS – Pathogenesis • Toxic shock syndrome toxin-1 (TSST-1) • 90-100% of mentrual-related cases (MRTSS) • 40-60% of nonmenstrual cases (NMTSS) • Enterotoxin B: 23% • Enterotoxin C: 2% • Enhanced production: • Neutral vaginal pH • Increase in vaginal pO2 and pCO2 • Synthetic fibers in tampon composition

  22. STSS – Pathogenesis • TSST-1 & enterotoxins = Superantigens: • Nonspecific T-lymphocyte stimulation without normal antigenic recognition • Ad 20% Result: massive production of cytokines • Release of IL-1, IL-2, TNF, interferon

  23. STSS – Pathogenesis • Immunitary response from host plays an important role in pathogenesis • 70-80% of 18 y.o. have antibodies to TSST-1 • 90-95% at 40 y.o. • Pts who dev STSS are unable to produce antibodies • Frequent recidival

  24. STSS – Clinical presentation • Sx on presentation: • Tachycardia 80% • Fever 70-81% • Hypotension 44-65% • Confusion 55% • Localized erythema 44-65% • Scarlatin-like rash 4%

  25. STSS – Clinical presentation • Rapid onset of sx: • Day 3-4 of menses • Day 2 post-operative

  26. STSS – Clinical presentation

  27. STSS – Clinical presentation

  28. STSS – Dx criteria • CDC 1990: Clinical manifestations • Fever >38.9 • Rash – diffuse macular erythrodema • Desquamation – 1-2 after onset, palms and soles • Hypotension (SBP<90 mmHg) • Multisystem involvement(3+): • GI (V, diarrhea, abdo pain) • Muscular (myalgias, CK X 2) • Mucous membrane (vagnal, conjunctival hyperemia) • Renal (CreatX2 or sterile pyuria) • Hepatic (bili or ALTX2) • Hemato (plt <100 000) • CNS (disorientation and alteration in consciousness)

  29. STSS – Dx criteria • CDC 1990: Laboratory criteria • Negative results on the following tests , if obtained: • Serologic test for Rocky Mountain spotted fever, leptospirosis, measles • Blood, throat, CSF cultures - (blood cultures may be + for Staph aureus)

  30. STSS – Dx criteria • CDC 1990: Case classification • Definite case: all 6 criterias • Probable case: 5 on 6 criterias In the absence of clinical markers, strict application is warranted • Excludes subclinical cases • Self-limited

  31. STSS – Dx • Isolation of Staphyloccocus aureus productor of exotoxins in a pt w compatible clinical picture • Not necessary for dx • Help in suspected cases • RARELY isolated in blood

  32. Case cont... • Our patient: • T> 38.9 • Diffuse rash • Hypotension • Multisystem involvement: • Diarrhea, V • Alteration in consciousness • Renal but not sufficient to meet the criteria • Plts 100 000 • Desquamation? Others tests – ? • Probable case

  33. Case cont... • Our patient: • Blood cultures – • Monotest – • Vaginal swab + for staph aureus • Urine culture – • C. Diff – in stools • Specific toxins search at Winnipeg. Results pending.

  34. STSS - Treatment • Treatment of support: • Agressive fluid support w isotonic NS or colloids: ad 10-20 L/24 hres • Vasopressor/inotrope infusion as necessary • Surgical treatment: • Removal of foreign objects: • Tampons • Nasal packing • Surgical debridement of scars: even if wound doesn’t look bad • I & D if abcess

  35. STSS - Treatment Therapy guided at stopping toxin production • Antimicrobial agents: • Have not been shown to affect outcome • IN VITRO: • Clindamycin inhibits protein synthesis – inhibition of TSST-1 • Anti-staph peni, cephalosporin may promote TSST-1 production • No clinical studies

  36. STSS - Treatment Therapy guided at stopping toxin production • Antimicrobial agents: • Recommandation: • Clindamycin 900 IV q8 +/- cloxacillin 2g IV q12 • Clindamycin 900 IV q8 +/- vancomycin 1g IV q12 for MRSA

  37. STSS - Treatment • Additional therapies: • Consider Intravenous immunoglobulin (IVIG): • If patients remains unstable • Contains antibodies to TSST-1 • Sporadicaly reported to have salutary effect; controlled trials are incomplete • Corticosteroids: • May accelerate clinical improvement and diminish neuro sequelae • Experimental agents

  38. Case: evolution • Tx: • Cloxacillin + tazocin IV X 2 d • then cloxacillin IV x 4 d • then Keflex PO x 4 d • Hemodynamic stabilisation w 4 L NS and 2 L of Pentaspan the first night • No need for inotropes or additionnal therapies • Progressive improvement of general condition

More Related