Fever, Rash, and Lung Crackles in a 25-Year-Old Woman

Jansen Tiongson, MD; John Sakles, MD; Harvey W. Meislin, MD


August 13, 2020

The initial treatment of TSS remains the same, regardless of the bacterium causing the TSS. Crystalloids and inotropic agents are used to treat hypovolemic shock, with close monitoring of the patient's mean arterial pressure and central venous pressure. Targeted antibiotics are given; penicillin or a beta-lactam antibiotic is used for treating group A streptococci, and vancomycin or a semisynthetic antistaphylococcal penicillin is used for staphylococcal TSS.

Clindamycin has emerged as the standard agent; it has an 83% more favorable outcome than penicillin or beta-lactam antibiotics (14%).[3] As opposed to penicillin, clindamycin is not affected by the size of the inoculum, has a longer postantibiotic effect, and better facilitates phagocytosis by inhibiting the production of the antiphagocytic M protein. In addition, clindamycin reduces TSST-1 levels by up to 90%, whereas penicillin or other beta-lactam antibiotics may increase TSST-1 levels because they lyse or alter the bacterial cell membrane.

Other adjunctive therapies, such as intravenous immunoglobulin, hyperbaric oxygen, and anti-tumor necrosis factor antibodies, are still in research phases at this time.[3,8] The role of activated protein C remains unproven.

The respiratory status of the patient in this case steadily improved after admission to the intensive care unit, and she was extubated 48 hours later. She continued to receive clindamycin and meropenem.

A lumbar puncture showed normal glucose and protein levels, with no WBCs, a negative Gram stain, and negative cultures. The patient's HIV, influenza A/B antigens, Coccidioides immitis, and infectious mononucleosis cultures were all negative, as were her blood, urine, and respiratory cultures. The TSST-1 antibody titer returned two weeks later as positive, and her ASO titer was normal.

Therapy was converted to oral antibiotics, and the patient's renal function and WBC count slowly normalized. She was discharged to home 14 days after her initial presentation. The patient's final discharge diagnosis was staphylococcal TSS, probably from a respiratory illness (such as pneumonia).


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