A 34-year-old woman, gravida 2 para 2, comes to the emergency department due to 2 days of fever, rash, and focal perineal pain. The patient was discharged 10 days ago after an uncomplicated spontaneous vaginal delivery at 38 weeks gestation. She had a second-degree perineal laceration that was repaired with suture. The patient has been using a perineal pad but no intravaginal packing after delivery. She has no chronic medical conditions and no drug allergies. Temperature is 40 C (104 F), blood pressure is 86/54 mm Hg, pulse is 132/min, and respirations are 24/min. The neck is supple. Pulmonary examination reveals bilateral crackles. The abdomen is soft and nontender. A diffuse macular rash is present over the trunk. On pelvic examination, the perineal laceration is tender, but there is no redness or swelling. The uterus is nontender on bimanual examination. Leukocyte count is 20,400/mm3 with 95% neutrophils. Which of the following is the most appropriate treatment for this patient?
Staphylococcal toxic shock syndrome | |
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This patient's high fever, hypotension, and diffuse macular rash in the setting of a postpartum wound suggests Staphylococcal toxic shock syndrome (TSS). Although classically associated with a retained foreign body (eg, tampon, nasal/vaginal packing), approximately 50% of cases occur due to an underlying surgical or postpartum wound infection. TSS is caused by the release of bacterial exotoxins (eg, TSS toxin-1) that bind directly to class II major histocompatibility complexes (ie. they bypass normal intracellular antigen processing), and activate T cells indiscriminately, leading to the massive release of inflammatory cytokines.
Manifestations include fever, shock (eg, hypotension, tachycardia), a diffuse macular rash that may include the palms and soles, and multiorgan failure (eg, altered mentation, bilateral crackles). Patients require aggressive fluids (and sometimes vasopressors), removal of the retained foreign body (if present), surgical debridement (in the setting of wound infection), and treatment with empiric antibiotics, including:
Vancomycin, which provides bactericidal activity against methicillin-resistant Staphylococcus aureus (MRSA)
Clindamycin, which prevents production of bacterial exotoxins by blocking the bacterial ribosome
A penicillin/beta-lactamase inhibitor (eg, piperacillin-tazobactam), cefepime, or a carbapenem, which provides additional bactericidal activity
(Choice A) Ceftriaxone, a third-generation cephalosporin, treats methicillin-sensitive Staphylococcus aureus. However, because TSS is immediately life-threatening, patients also require vancomycin to provide coverage for MRSA strains and clindamycin to halt bacterial exotoxin production.
(Choice B) Postpartum endometritis is typically treated with clindamycin and gentamicin. Although patients usually present with fever and leukocytosis, they typically have significant abdominal pain and uterine tenderness. In addition, the presence of a diffuse macular rash in the setting of a postpartum wound makes TSS more likely.
(Choice C) Doxycycline treats Rickettsia rickettsii, the causative agent of Rocky Mountain spotted fever. Although this illness causes fever and rash, the rash begins on the wrists and ankles before spreading to the trunk and palms and soles; in addition, the rash tends to start several days after other symptoms and rapidly turns petechial.
(Choice D) Penicillin is often used for secondary syphilis, which may present with a diffuse rash but does not cause shock. Metronidazole is primarily employed to treat anaerobic bacteria (eg, gastrointestinal infection). This regimen would not adequately treat TSS.
Educational objective:
Toxic shock syndrome is usually caused by Staphylococcus aureus exotoxins. Most cases are linked to a retained foreign body (eg, tampon, nasal packing) or surgical/postpartum wound infection. Patients present with rapid-onset fever, hypotension, tachycardia, and a diffuse, macular rash. Treatment includes supportive care, foreign body removal (if present), surgical debridement (in the setting of wound infection), and antibiotic therapy with vancomycin, cefepime, and clindamycin.