The Pre-brief
It’s another long and busy shift in the Emergency Department, and you just finished admitting your third patient with COVID-19. As you are about to see the next patient, you feel a tap on your shoulder and turn around to see the masked face of a concerned nurse urging you to see her patient who was just wheeled in by EMS.
As you quickly screen the patient from outside of her room and begin to you understand why the nurse was worried. The patient is a female in her mid-fifties and looks very ill. She is tachycardic in 130s with an initial blood pressure of 90/60, febrile, and looks oddly flushed as if she just got out of a sauna session.
She can tell you that she hasn’t felt well for a couple of weeks since her hysterectomy surgery and was afraid to go out because she thought she had COVID. She recently went to a local clinic where she was told that she likely has a viral illness. She was instructed to self-quarantine at home and take anti-inflammatory medications while waiting for her COVID-19 test results. Unfortunately, her condition continued to worsen over the next few days, and she decided to call EMS. You look closer at the rash, and wonder if this can be something different altogether.
A Diagnostic Challenge
Although tampons were linked to staphylococcal toxic shock syndrome (TSS), there are many other causes; nasal packing, contraceptive sponges and diaphragms, osteomyelitis, mastitis, surgical wounds, postpartum infection, undrained abscesses, gynecological procedures, and ulcers have all been linked to TSS. Unfortunately, in many TSS cases, an exact cause cannot be elucidated.
The clinical manifestations of TSS are caused by cytokine-mediated responses to the TSST-1 toxin (Sounds like COVID, right?). Early in the disease process, the symptoms are generally nonspecific: fever, malaise, weakness, myalgia, dizziness, and vomiting. These symptoms can be easily attributed to a viral illness (especially in the middle of a pandemic), as in our patient’s case resulting in a dangerous delay in diagnosis. Hypotension and altered mental status is a late presentation of TSS associated with dire outcomes.
The characteristic rash of TSS should alert clinicians to consider this diagnosis. It is generalized, reddened, flat, and nonpruritic. It is also associated with mucous membrane hyperemia (conjunctivae, oropharynx, and genitalia). Desquamation of the hands and soles of the feet occurs anywhere between 3 days and 2 weeks after disease onset. Many patients with staphylococcal TSS present before the onset of desquamation.
The CDC criteria for staphylococcal TSS require the following clinical features1:
- Fever: temperature greater than or equal to 102.0°F (greater than or equal to 38.9°C)
- Rash: diffuse macular erythroderma
- Desquamation: 1-2 weeks after onset of rash
- Hypotension: systolic blood pressure less than or equal to 90 mm Hg for adults or less than the fifth percentile by age for children aged less than 16 years
- Multisystem involvement (three or more of the following organ systems):
- Gastrointestinal: vomiting or diarrhea at onset of illness
- Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal
- Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia
- Renal: blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria (greater than or equal to 5 leukocytes per high-power field) in the absence of urinary tract infection
- Hepatic: total bilirubin, alanine aminotransferase enzyme, or aspartate aminotransferase enzyme levels at least twice the upper limit of normal for laboratory
- Hematologic: platelets less than 100,000/mm3
- Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent
Don’t hesitate to resuscitate
The most challenging task is timely and correct staphylococcal TSS. This is an especially difficult diagnosis to make in the midst of the COVID-19 pandemic. Avoid anchoring bias and do what you do best; resuscitate – aggressively! These patients will require fluid and broad-spectrum antibiotics. Labs and imaging should be directed at culturing potential sources and monitoring for complications. Watch for disseminated intravascular coagulopathy (DIC), acute respiratory distress syndrome (ARDS), and myocardial infarction (MI). Involve your surgical colleagues early if operative source control is needed.
The Debrief
- Take a second to consider other differential diagnoses. Maybe it’s not COVID. Avoid anchoring bias.
- The most crucial step in making the diagnosis of staphylococcal TSS is to simply consider the diagnosis.
- Think beyond tampons! There are many causes of staphylococcal TSS. Consider the possibility of not finding a cause.
- Be aggressive with fluid management and go broad with antibiotics.
