Review Question - QID 107258

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Toxic Shock Syndrome QID: 107258 (M2.ID.15.4678)

QID 107258 (Type "107258" in App Search)

A 22-year-old female is hospitalized with fever and hypotension refractory to fluid resuscitation. Her vital signs are as follows: T 39.0 C, P 110, BP 86/52, RR 12, SpO2 98%. Physical exam reveals diffuse macular erythroderma (Figure A) and the following findings of the conjunctiva (Figure B) and oral cavity (Figure C). She complains of muscle aches as well as diarrhea for the past 3 days. She denies any recent travel or new sexual partners. She had her last menses 4 days ago and always uses a tampon. What is the most likely organism to cause this patient’s presentation?

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A single-stranded, negative-sense, enveloped RNA virus

0/25

An aerobic, gram-negative coccobacilli

2/25

An aerobic, gram-positive cocci in chains

20%

5/25

A facultative anaerobic, gram-positive cocci in clusters

68%

17/25

A coiled, obligate aerobic, spirochete

0/25

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This patient meets clinical criteria for toxic shock syndrome (T > 38.9 C, SBP < 90 mmHg, erythroderma, and multisystem involvement). In a female patient with recent tampon use, staphylococcus aureus is the most likely cause of toxic shock syndrome.

Toxic shock syndrome is caused by superantigens, which directly link MHC class II molecules on antigen presenting cells to T-cell receptors causing a massive release of inflammatory cytokines. Menstrual cases are caused by the superantigen toxic shock syndrome toxin-1 (TSST-1), produced by S. aureus that colonizes the vagina. Super absorbent tampons introduce oxygen to the anaerobic vaginal environment, facilitating production of TSST-1.

Figure A demonstrates erythroderma. Figure B shows hyperemia of the conjunctiva. Figure C demonstrates strawberry tongue.

Incorrect Answers:
Answer 1: Measles is characterized by cough, coryza, and conjunctivitis, as well as Koplik’s spots on the buccal mucosa. A generalized, maculopapular rash begins on the head and neck and spreads to the remainder of the body.
Answer 2: Conjunctival erythema and multisystem organ involvement is seen in rocky mountain spotted fever. The rash, however, begins on the wrists and ankles and spreads to the palms and soles while becoming purpuric.
Answer 3: Group A streptococci can cause toxic shock syndrome, but cases of menstrual toxic shock syndrome are most commonly caused by S. aureus.
Answer 5: Conjunctival erythema and multisystem organ involvement is seen in leptospirosis. The rash, however, is transient (lasts < 24 hrs) and purpuric.