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A 23-year-old female college student presents to student health services with "the flu." She has noted a fever of 38.9 C and myalgias. She is treated with symptomatic care and discharged back to her dormitory. Three hours later her roommate finds her lethargic and difficult to arouse. On exam her blood pressure is 70/30 with a pulse of 145. Her neck is supple but she is lethargic and complaining of severe muscle aches. She denies headache. There is a fine macular rash over her abdomen.
Which of the following is an important historical factor in this case?
A) History of splenectomy.
B) Use of tampons.
C) History of acetaminophen overdose.
D) A and B.
E) A, B, and C.
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2)The patient is able to give you the additional history that she does not use tampons and has not taken any medication except for occasional acetaminophen and ibuprofen in recommended doses. She has her spleen.
On the basis of this information you decide that:
A) It is unlikely that this is toxic shock syndrome given that she does not use tampons.
B) The combination of acetaminophen and ibuprofen in this patient with the flu has led to hypotension.
C) Given that she is immunocompetent and has her spleen intact, this cannot be sepsis since it started so quickly.
D) Toxic shock, which was a big problem in the 1980s and early 1990s, no longer occurs since the advent of less absorbent tampons.
E) None of the above.
3)The organism(s) responsible for toxic shock syndrome are:
A) Staphylococcus.
B) Haemophilus influenza.
C) Klebsiella.
D) D) Streptococcus.
E) A and D.
4)Which of the following would you NOT expect to find on laboratory testing?
A) Creatinine of 2.0 mg/dl (normal 1 mg/dl).
B) Elevated ALT/AST.
C) Platelets of 100,000-150,000/mm3 (normal 250,000/mm3).
D) Elevated CPK.
E) All of the above would be found in toxic shock syndrome.
5)Which of the following treatments would be important in this patient?
A) Nafcillin to treat the sepsis.
B) Fluids for IV hydration.
C) Dopamine as a pressor.
D) Dexamethasone.
E) B and C.
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2...E
3....A
4....E
5...A
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1)The correct answer is D. Patients with a splenectomy can get sick rather rapidly from pneumococcal and other encapsulated bacterial sepsis. Thus, knowledge of a patient's splenectomy status is critical when dealing with infectious disease. Answer B is important because this patient may have toxic shock syndrome, which is related to the use of tampons. Answer C is not important. First, shock is not a prominent feature (if it occurs at all) in acetaminophen overdose. Additionally, acetaminophen overdose is not associated with a rash.
2)The correct answer is E. A is incorrect because up to 50% of cases of toxic shock occur as the result of Staphylococcal infections unrelated to tampons. These may be ingrown toenails, infected abrasions, etc. Answer B is incorrect. If you decided to vote for this, back home for you. We frequently use acetaminophen and ibuprofen together without difficulty. Answer C is also incorrect. Splenectomized patients are more prone to sepsis from encapsulated organisms, but the fact that the patient has a spleen does not grant invincibility. Sepsis obviously occurs in the normal host as well. Finally, D is incorrect. While absorbent tampons are a major culprit in toxic shock syndrome, as noted above, there are other causes. Thus, toxic shock syndrome is not going away anytime soon.
3)The correct answer is E. There are two types of toxic shock syndrome, one caused by Staphylococcus and the other by Streptococcus. There are certain subtypes that make the toxin responsible for toxic shock syndrome. Not all strains of these bacteria make the toxins (which are called exotoxins), and only certain hosts are thought to be susceptible due to a lack of the appropriate antibodies. Of note, most patients with Streptococcal toxic shock are bacteremic, whereas those with Staphylococcal toxic shock are not.
4)The correct answer is C. By definition, the platelet count should be < 100,000/mm3. All of the other findings are representative of the multisystem dysfunction that categorizes toxic shock syndrome.
5)The correct answer is E. IV fluids and dopamine are indicated for support of this patient. Answer A is of special note. Patients with classic toxic shock syndrome (Staphylococcal) are not septic. Therefore, while an antistaphylococcal drug is important (as is locally treating the site of infection with incision and drainage, toenail removal, etc.), the antistaphylococcal drug is not to treat sepsis.
