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Toxic shock syndrome, a potentially lethal multisystem illness that usually affects menstruating women, is characterized by the acute onset of fever, hypotension, skin and mucous membrane changes, nausea, vomiting, diarrhea, myalgias, capillary leak, vascular collapse and multiorgan dysfunction. The disease is mediated by toxin produced by distinct strains of Staphylococcus aureus. We describe a case in which a toxin producing strain growing in a continent urinary diversion produced toxic shock syndrome.
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PMID:Toxic shock syndrome: a complication of continent urinary diversion. 153 57

Staphylococcus aureus produces many extracellular products often referred to as toxins, some with definite disease-causing potential. The enterotoxins A through E are common causes of acute food poisoning characterized by a short incubation period after ingestion of performed toxin followed by nausea, vomiting, abdominal pain, and diarrhea. The epidermolytic toxins (A, B) are absorbed from a local site of colonization or infection and affect the granular cell layer of skin to cause the painful erythroderma and desquamation of the scalded skin syndrome. Other unique S. aureus strains produce one or more products that appear to be formed at sites of focal infection (wound infection, vagina during menstruation and tampon use) with systemic absorption and generalized effects resulting in toxic shock syndrome.
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PMID:Staphylococcal toxin syndromes. 315 68

Toxic shock syndrome (TSS) occurs most often in menstruating women who use tampons. It also occurs following surgical procedures. The occurrence of three cases after nasal surgery prompted us to determine the incidence of this complication and to evaluate possible risk factors. Our cases showed that onset of TSS after surgery is rapid. Early symptoms include nausea, vomiting, diarrhea, erythroderma, and hypotension. The wound does not appear grossly infected. Incidence of TSS after nasal surgery during 1980 through 1983 was 16.5 per 100,000, higher than the incidence in women of menstrual age. Splints were used more frequently in patients who developed TSS than in patients who did not. Nasal packing was used in all patients with TSS and in 98% of all patients. Topical or systemic antibiotics did not have a demonstrable protective effect.
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PMID:Toxic shock syndrome after nasal surgery. Case reports and analysis of risk factors. 394 41

4 reported cases of toxic shock syndrome (TSS) occurred in late 1983 among users of the vaginal contraceptive sponge (VCS). All patients manifested fever, hypotension, diffuse rash, desquamation, nausea, vomiting, myalgias, mucous membrane hyperemia, and vaginal discharge. All were hospitalized, treated with intravenous fluids and antimicrobial agents, and recovered. Vaginal cultures in each case were positive for Staphylococcus aureus. The VCS is made of polyurethane impregnated with the spermicide nonoxynol-9 and is intended to provide 24 hours of contraception. During clinical trials the average woman using only this method of contraception used 10 sponges/month. Package labels state that if symptoms compatible with TSS develop users should seek medical care. Women who use the VCS should read the package insert carefully and follow the manufacturer's directions. Women who have had TSS should consult a physician before using a VCS and so should postpartum women. If it is assumed that the 4 cases reported were attributable to a VCS, a minimum estimate of the incidence of nonmenstrual TSS associated with VCS use would be 10/year/100,000 women who use only VCS compared to 5-10/year/100,000 who use tampons. The use of contraceptive methods other than the VCS may also affect the risk of developing TSS; cases of nonemnstrual TSS among diaphragm users have been reported. Conversely the use of oral contraceptives may reduce the risk of developing menstrual TSS.
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PMID:Toxic-shock syndrome and the vaginal contraceptive sponge. 631 70

In Pennsylvania, a 29-year-old woman was admitted to Temple University Health Sciences Center in Philadelphia with hypotension (100/80 mmHg), fever (105.3 degrees Fahrenheit), and a diffuse, nondesquamating erythroderma. Five weeks earlier, she had delivered her last child vaginally. Three days before admission, she had undergone endotracheal intubation so surgeons could perform a laparoscopic tubal ligation with Falope Rings. Two days before the tubal ligation, she had had a sore throat. She experienced no surgical complications and was discharged the same day as the operation. The day before her latest admission, she experienced nausea, vomiting, diarrhea, fever, chills, and diffuse abdominal pain. Upon admission, her surgical incisions were clean and dry and had no erythema. Her pulse rate was 140 beats/minute. Her respiration rate was 20/minute. The white blood cell count was 15,200 cells/cu. m (71% neutrophils, 23% band forms, 2% lymphocytes, and 4% monocytes). Her potassium level was 3.2 mmol/l. The anion gap was 22. All blood and urine cultures were negative. She experienced mild uterine tenderness. Upon admission, physicians administered ticarcillin-clavulanate and vancomycin for suspected postoperative pelvic infection. After learning that cervical and pharyngeal cultures were positive for Streptococcus pyogenes, physicians changed to ampicillin, 1 g intravenously every 6 hours. On the 6th day, she was discharged and prescribed 500 mg oral amoxicillin every 8 hours for 2 weeks. Within 2 weeks, she felt fine, had a normal physical examination, no fever, and no rash. The major signs and symptoms indicated a toxin-mediated illness. Both mucosal surfaces colonized by S. pyogenes were manipulated during laparoscopy and manipulation may have caused minor tissue injury and hyperemia with subsequent dissemination of streptococcal toxin. In conclusion, the patient had a S. pyogenes toxin-induced toxic shock-like syndrome that mimicked a pelvic wound infection with gram-negative septicemia.
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PMID:Streptococcal toxic shock-like syndrome as an unusual complication of laparoscopic tubal ligation. A case report. 799 32

Toxic shock syndrome (TSS) is a serious, potentially life-threatening condition resulting from an exotoxin of Staphylococcus aureus. Presenting symptoms include high fever, diarrhea, nausea, and vomiting progressing to hypotension, oliguria, conjunctival hyperemia, and an erythematous rash over the trunk, abdomen, and extremities. TSS has been associated both with and without the use of tampons during menstruation, postsurgical infections, and stab wounds, and can occur in postrhinoplasty patients with and without nasal packing. There has been one case reported in the literature of TSS associated with suction-assisted lipectomy (SAL). This article discusses the diagnosis and treatment of two cases in which the patients developed TSS after outpatient use of SAL. In the first case, an abdominoplasty and SAL were performed in a healthy young female. The second case involved the harvesting of abdominal fat via syringe suction and subsequent facial fat injection in a female with systemic lupus erythematosus and severe facial atrophy.
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PMID:Toxic shock syndrome associated with suction-assisted lipectomy. 801 20

A thirty-three year old female presented to our emergency department complaining of severe abdominal pain, nausea, and vomiting. On physical examination she was hypotensive with a firm, tender abdomen, cervical motion tenderness and a diffuse erythematous rash. A surgical diagnosis of Acute Pelvic Inflammatory Disease was made during laparoscopy. Coagulant studies, liver function tests, culture results, and the desquamation of the patient's palms led to the additional diagnosis of Toxic Shock Syndrome. A literature search failed to reveal any similar cases of Pelvic Inflammatory Disease (PID) and Toxic Shock Syndrome (TSS) occurring concomitantly. Patients may present severely ill with either of these disease entities but potential for serious illness is greater when both of these syndromes occur in the same patient. We conclude that in patients with a similar presentation, the symptoms should not be attributed completely to PID without further investigation and consideration of a concomitant disease process including TSS.
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PMID:A 33-year-old white female with abdominal pain, nausea, vomiting and hypotension. 834 May 81

We report the case of a 21-year-old man who had been developing acute renal failure with Methicillin-resistant Staphylococcus aureus (MRSA) colitis and sepsis. He was admitted for consciousness disturbance, nausea, vomiting, and diarrhea. Oliguria was also observed and his serum creatinine level was elevated to 10 mg/dl. Urinary protein was positive and an abundance of hyaline cast were seen in urinary sedimentation. Diarrhea and pyrexia were prolonged and serum C-reactive proteins were elevated, but lymphocyte and leukocyte counts temporarily decreased from the 3rd to the 6th hospital day and remained low until normalizing after the 14th day. His clinical symptoms improved with hemodialysis (HD) and effective antibiotic therapies. An MRSA strain producing toxic shock syndrome toxin-1 (TSST-1), a super antigen which specifically stimulates human V beta 2-positive T cells, was separated from his feces and blood. To ascertain the cause of his renal dysfunction, a renal biopsy was performed on the 8th day. His renal histology revealed acute interstitial nephritis with severe inflammatory cell infiltration around the medullary areas without glomerular changes. Most of the infiltrated cells were small monocytes, and lymphoid cells were rich in the interstitium. With immunohistochemical staining, over 70% of T-cells were V beta 2-positive. TSST-1-producing MRSA was detected in his blood specimen. Furthermore, V beta 2-positive T cells were accumulated in the renal intersititium, and transient lymphocytopenia was observed. These data suggested the following possible pathogenesis for interstitial nephritis: TSST-1 acts as a super antigen in the renal interstitium where major histocompatibility complex (MHC) is class-2-positive, thereby resulting in interstitial nephritis with T cell migration.
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PMID:[A case of interstitial nephritis induced by a super antigen produced by methicillin-resistant Staphylococcus aureus (MRSA) presenting as acute renal failure]. 1036 25

Toxic Shock Syndrome (TSS) secondary to mastitis is seldom described. We present a case of TSS due to postpartum mastitis caused by Methicillin-resistant Staphylococcus aureus (MRSA). Five weeks after giving birth to a healthy boy, a 23-year-old secundipara was readmitted to the hospital with a fever, systemic erythema, nausea, vomiting, diarrhea, diffuse myalgia, generalized itching, orthostatic syncopes, photophobia, oligurea and pain in the left breast. Laboratory data on admission revealed deteriorated renal and coagulation function. Administration of Vancomycin, Imipenem, dopamin and nafamostat mesilate was started immediately after admission, that was effective. The patient recuperated steadily over the next week with apparent desquamation of the skin on her face, breast and extremities especially palms and soles. MRSA isolated from her milk was coagulase type II producing toxic shock syndrome toxin-1 (TSST-1) and enterotoxin C. Also immunoglobulin G against TSST-1 was not detected from her sera both on admission and on discharge, which suggested that the patient belongs to the high risk group of TSS recurrence.
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PMID:[A case of toxic shock syndrome secondary to mastitis caused by methicillin-resistant Staphylococcus aureus]. 1171 66

Federal investigators have failed to substantiate a suspected link between the contraceptive sponge and toxic shock syndrome (TSS). In September the US Food and Drug Administration (FDA) reported the case of a woman who inserted the contraceptive sponge last July 17 and removed itthe following day. About 6 hours later she noted the sudden onset of a fever of 104 degrees Farenheit, nausea, redness, shaking chills, and an inflamed vagina. Cultures from the sponge revealed S. aureus and S. epidemis. There was initial concern that the case may have represented early TSS. A toxin produced by certain strains of S. aureus is thought to cause TSS. The syndrome includes a fever greater than 102 degrees, rash, blood pressure less than 90mmHG, peelin g skin on the palms and soles 1-2 weeks after onset, and involvement of 3 or more of the following organ systems: gastrointestinal, muscular, mucous membrane, renal, hepatic, hematologic,or central nervous system. FDA medical Officers Dr. William J. McCann told "Contraceptive Technology Update" (CTU) that the reported case failed to fill the Centers for Disease Control criteriaof the diagnosis of TSS. Because the woman has been treated with antibiotics early in the course of her disease, McCann said he could not entirely exclude the possibility that she might have developed TSS if she had gone untreated. He added that the possibility was "remote". Dr. Gail Bolan, CDC epidemiologist, told CTU that "antibiotics do not seem to affect the outcome of the original episode" of TSS cases. She commented that milder forms of TSS might exist that may not meet CDC's strict case definition. Without a specific test, there is no way to separate milder TSS cases from viral or other diseases that may appear similar. According to Deborah Gaynor, the sponge's package insert states that clinical trials were not large enough to assess the risk of TSS. The sponge is not recommended for use during menstration. Gaynor cites a variety of reasons why the contraceptive sponge does not cause TSS: Remarketing trials of the sponge included more than 1000 women years of experience without a reported case of TSS; nonoxynol 9 spermicide and citric, ascorbic, and benzoic acids in the sponge are hostile to S. aureus; unlike tampons, the sponge is not highly absorbant and does not cause microabrasions of the vagina; and during testing, contraceptive sponges were innoculated with the Harrisburg strain of S. aureus known to cause TSS fatality, and after incubation in growth medium for 28 days the S. aureus failed to grow in the innoculated sponges.
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PMID:Investigators unable to substantiate suspected link between sponge, TSS. 1233 16


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