17 year old male

with 1 day of fever and

rash
Scott Wallace MD PGY 2
Morning report 6/22/15

HPI
Patient presents to clinic with fever and body aches
since last night.
Mother reports that patient was healthy and acting
normally prior to last night when he developed fever to
103 followed by generalized aches.
Patient reports that he then developed headache and
neck ache this morning (approximately 4 hours ago)
Patient also developed whole body erythematous,
nonpruritic rash this morning.

HPI
Patient was recently diagnosed with strep
pharyngitis via rapid strep test at urgent
care. Is currently on day 9 of 10 of penicillin.
Patient recently returned from Thailand 3
weeks ago where he was on a service trip in
rural Thailand.
There, patient cut his left shin on a boat. Patient
was staph positive on culture in urgent care and
started on Bactrim. Is currently on day 9 of 10.

HPI
Patient reports fatigue on ROS
Patient reports no drainage or redness from
left shin would. Denies any pain at wound.
Patient and mother deny any cough,
congestion, nausea, vomiting, diarrhea,
abdominal pain, joint pain/swelling, sore
throat, chest pain, dyspnea.

HPI
EXPOSURE HISTORY:
Swam in rivers in Thailand
No animals at home. No known exposure to
any animals while in Thailand
No recent tick bites
Multiple mosquito bites while in Thailand
No foreign visitors or known exposure to ill
contacts.

More History
PMH: Osteoma removed 2 years ago. No other surgeries
or hospitalizations. No chronic medical diseases reported.
KNDA
Medications: penicillin and bactrim
FH: No recurrent infections, known immune deficiency, or
autoimmune disease. No know ill contacts
Social Hx: Is about to start senior year in high school. Gets
As and Bs. Denies substance use and sexual activity.

EXAM:
VS: T 40.5, HR 98, RR 18, BP 128/72, Sats 98% on room air.
GEN: Patient appears uncomfortable though is cooperative with questions and exams. Becomes
diaphoretic toward end of encounter.
HEENT: NCAT, Bilateral conjunctivitis (nonpurulent), no rhinorrhea/congestion, TM pearly grey
bilaterally, MMM, no tonsillar hypertrophy, no oral lesions.
NECK: FROM, no meningismus. No LAD
CV: RRR, no m/r/g. Pulses 2+ at radial and DP. Cap refill 3 seconds
RESP CTAB, no w/r/r, no retractions
ABD + BS, soft NTND. No HSM.
Ext: generalized reported tenderness while palpating muscles. Wound over left shin (quarter
(3cm) size with 2-3mm rim of erythema around wound with no current discharge/drainage/foul
smell. No splinter hemorrhages, oslar nodes, or other lesions noted. No edema.
SKIN: diffuse maculopapular rash over face, trunk, upper and lower extremities and palms but not soles. No
mucocutaneous involvement. No excoriations, vesicles, bullae, desquamation, or skin breakdown (with
exception of wound on left shin noted above)
NEURO: AO x 3, CN 2-12 intact, symmetric strength, sensation intact, rapid alternating movements intact,
symmetric 1+ reflexes at petellar and brachioradialis. Stable gait.

Summary slide
17 year old male with 1 day of fever,
myalgia, headache, and rash.

DDX Infections

Gram negative sepsis

Staph Aureas
TSS
Scalded Skin
GAS
Toxic Shock syndrome
Necrotizing Fasciitis
Cellulitis
Myositis
Scarlet Fever
Meningitis
S. Pneumo
N. Meningitidis

Mycoplasma
SJS, EM, TEN, DRESS
Viral:
EBV, CMV
Enterovirus
Varicella
Measles
Rubella
Thailand specific
Typhoid Fever
Maleria
Dengue Fever
Hepatitis A/B
Japanese
Encephalitis
Yellow Fever
Rabies

DDX Continued

CV
Endocarditis

Rheum
Rheumatic Fever
Kawasaki
SLE
polymyalgia rheumatica
Dermatomyositis

Heme/onc
Leukemia
Lymphoma
Solid tumor

Course:
Patient in the ED initial vitals: T 40.5, HR
122, BP 119/66, sating 100% on RA
ED course: He was given 2 boluses of NS
and one dose of ceftriaxone, blood cultures
were drawn along with a CMP and CBC with
diff, enterovirus by PCR, PT, PTT, and Chest
Xray.
Patient became hypotensive. Received 5L
IVFs. Started on dopamine and
norepinephrine and admitted to PICU.

Labs

CBC: WBC 6.3 (18B, 65PMN, 14L, 2M, 1E), hgb 16.5, plt 135
Na 138, K 4.4, CO2 19, iCa 1.12, glu 110
Cr 1.08, BUN 13
ALT 20, AST 26, Alk Phos 90
RFA neg, Enterovirus/parecho neg, malaria neg
UA: 1+ ketones otherwise negative
ESR 4, CRP 4.0
PT 16.7, PTT 29, fibrinogen 304
CSF: glu 74, cell count <1, protein 45
Cultures: Negative (blood, urine, CSF)
CXR: Mild streaky perihilar opacities may represent atelectasis or
edema.
Doppler LE: normal
TSST-1 Ab positive, Enterotoxin B/C Ab negative

Course
Patient maintained on vanc, clinda,
and ceftriaxone initially.
Quickly weaned off pressors.
Transferred to floor on HD #1
Vancomycin and Ceftriaxone
discontinued at 48 hours negative
cultures.
Clindamycin continued for 10 day
course. Patient discharged on HD#3

Toxic Shock Syndrome

Initially described in 1978
Initially seen predominately in
menstruating females
Medial interval between onset of
menstruation and symptoms is 2-3 days
(similar time for postsurgical)

Now 40-60% are nonmenstruating type

Caused by Staph aureus or GAS

Staphylococcal Toxic Shock

Syndrome
Caused predominately by MSSA
Due to TSST-1 or enterotoxins (A, B, C, D, E, and H)
Note: 70-80% of teenagers develop ab to TSST-1 by
17-18 years of age

Clinical Manifestation:
Fever,
Hypotension: often rapid onset
Skin manifestations
Multiorgan involvement
Chills, headache, sore throat, myalgia, fatigue,
vomiting, diarrhea, abdominal pain, dizziness, syncope

Skin Manifestations in
Staphylococcal TSS:

involves skin and mucous membranes

can involve palms and soles
Severe cases can cause bullae and
petechiae
Late onset (1-2 weeks): can get
desquamation

CDC Diagnostic Criteria

Must have
Fever >38.9
Hypotension
Diffuse erythroderma
Desquamation (unless patient dies prior)
Involvement of at least 3 organ systems
If missing one of these criteria then can be
probable TSS
Do not require isolation of Staph aureus

Streptococcal TSS
Similar presentation
Risk factors:
<10years old or >60, cancer, renal
failure, burns, or immune suppressed
Associated with minor traumas, NSAIDs,
Recent surgery, viral infections (VZV or
influenza), post-partum

Diagnostic criteria
Isolation of GAS from a normally sterile site
Hypotension
Plus 2 of the following
Renal dysfunction
Coagulopathy
Liver dysfunction
Acute RDS
Erythematous macular rash (may desquamate)
Soft tissue necrosis (nec fasc, myositis,
gangrene)

Management of TSS
Supportive therapy with IVFs,
pressors, etc
Surgical drainage of identified sites if
present
Empiric Abx: Vancomycin and
Clindamycin
If MSSA: Clindamycin and oxacillin or
nafcillin
If MRSA: Clindamycin and
vancomycin or linezolid

References:
Redbook 2015
Uptodate
http://www.uptodate.com/contents/staphylococ
cal-toxic-shock-syndrome?
source=search_result&search=toxic+shock+s
yndrome&selectedTitle=1%7E105
http://www.uptodate.com/contents/epidemiolo
gy-clinical-manifestations-and-diagnosis-ofstreptococcal-toxic-shock-syndrome?
source=search_result&search=toxic+shock+s
yndrome&selectedTitle=2%7E105