CASE HISTORY 1

05/09/1990: The patient, a 16 year old female was well until 2 days prior to admission when she had a fever to 39.9°C and vomiting. On the morning of admission, she had loose stools, continued fever, and vomiting. She was seen by her local pediatrician who noted that she was hypotensive (BP 76/48 mmHg) with a heart rate of 120 beats/min and a temperature of 38°C. She had an erythematous rash, which was most prominent on her trunk. Cultures were obtained. The patient was given intravenous fluids and IV antibiotics and transported to the hospital, where she was admitted into the Pediatric Intensive Care Unit.

Laboratory studies indicated elevated liver enzymes, increased creatinine and blood urea nitrogen, and WBC count of 14,100 mm3 with 78% neutrophils and 18% band forms. The patient had begun her menstrual period 4 days before she became ill.

QUESTIONS

1. Does this patient have infection? Is it bacterial or Viral? What evidence do you have?   Answer

2. What are the potential sites for infection in this patient as judged from the clinical story?  Answer

3. What additional history would you like to have? How can infection be linked to her periods?  Answer

4.. Yes she did use tampons for her periods. Her blood pressure is low indicating that she may be in shock. What are the types of shock you can encounter with infection?  Answer

5. Which shock do you think the patient is in and why did you come to that conclusion?  Answer

6. What type of infections can lead to Toxic shock syndrome?  Answer

 7. What cultures would you consider obtaining form this patient  Answer

8. The vaginal culture was positive for many catalase positive, Gram positive cocci. What organism do you expect this to be?  Answer

9. What is the normal flora of Vagina? Since S. aureus is one of the normal flora of vagina how can you attribute significance to the culture results?  Answer

10. What virulence factor does this organism produce which is believed to be responsible for the signs and symptoms in this patient? What is the pathophysiology of Toxic shock syndrome? How do these toxins lead to the clinical manifestations?   Answer

11. What do you need to prove that the staphylococcus that has been cultured from vagina is responsible for the toxic shock in this patient?  Answer

12. This patient's isolate was shown to produce this virulence factor. This toxin in animal models has been shown to reproduce some of the same clinical characteristics of this disease as seen in humans. What is the significance of tampon use in this patient?  Answer

13.  When the association between super absorbent tampons and TSS became clear, this product was withdrawn from the US marketplace. With this suspension in sales came a marked decrease in the number of cases of TSS reported in menstruating women. Does that mean we do not encounter Toxic shock syndrome anymore?  Answer

14. What is our therapeutic strategy?  Answer

15. What are the clinical presentations of  S. aureus  infection?  Answer