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CLINICAL EXPERIENCE

Toxic Shock Syndrome in a Frail Elderlv Nursing Home Resident J

Bradley Bowman, MD, and Stephen R. Jones, MD, FACP ever is a common problem in nursing home residents.’ Pneumonia, urinary tract infection, and skin infection from pressure sores are routine and easily recognized causes. In some cases, however, the cause of fever is indefinite or obscure. More than a decade ago an ambiguous but dramatic constellation of findings-fever, erythroderma, vomiting, diarrhea, and hypotension followed by desquamation-was defined as the toxic shock syndrome (TSS).’ Typically, young women have been affected. TSS is rarely considered in the differential diagnosis of fever or multisystem disease in the elderly. We present a patient with a subtle and ambiguous presentation; fever was the most prominent feature. Using standard criteria, TSS was diagnosed. The probable source of the toxin was a methicillin-resistant Staphylococcus aureus which had colonized the vagina and uterine cervix.

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CASE REPORT A 66-year-old obese diabetic woman with a dense hemiparesis was transferred from a nursing home because of fever, lethargy, and hypotension. She had been discharged 4 days previously after an 8-day hospitalization for persistent fever and poorly controlled hyperglycemia. Twenty-five days prior to her initial admission she developed a fever while being treated with ciprofloxacin for an asymptomatic urinary tract infection. Urine cultures grew Enterococcus faecalis, reported as sensitive to ciprofloxacin (Figure 1). A vaginal discbarge at the time grew normal flora. Her fever, which lasted 7 days, abated 1 day after the 2-week course of ciprofloxacin was completed. No other source of infection was identified; the vaginal discharge persisted. Eleven days prior to admission, methicillin-resistant Staphylococcus aureus (MRSA) was cultured from the vaginal discharge. She was treated empirically with dicloxacillin and switched to cephalexin two days later. Testing showed in vitro resistance of the MRSA to both of these drugs. Her myalgias continued, and 8 days prior to admission she again became febrile. Diarrhea developed, and a progressive decline in functional status with increasing lethargy and confusion ensued. Captopril, ranitidine, insulin, and low-dose subcutaneous heparin had been given since her admission to the nursing home 6 weeks previously after a stroke ~

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From the Department of Medicine, Good Samaritan Hospital & Medical Center, Oregon Health Sciences University, Portland, Oregon.

JAGS 40:274-276, 1992 0 1992 by the American Geriatrics Society

had caused left hemiplegia and speech and swallowing dysfunction. Upon hospital admission the temperature was 37.4 C orally, the blood pressure 95/55 mm Hg, and the respiratory rate 24. The skin was unremarkable. The tongue was “strawberry-colored.” There was no evidence of focal infection in the lungs, abdomen, or urinary tract. Except for decreased cognitive function, the neurologic examination was unchanged from the last admission. There was mild drainage from the uterine cervix, and a culture grew Enterobacter cloacae but no MRSA. No pathogens were cultured from the stool, and no Clostridium difficile toxin was detected. The white blood count was 22.1 X 109/L with 10% bands, hemoglobin 118 g/L (11.8 mg/dL), platelets 209 X 109/L, Na+ 148, K+ 4.3, C1- 118 and HC03- 17 mmol/L. The creatinine, which 3 months earlier had been 203 pmol/L (2.3 mg/dL), was now 345 (3.9). No microorganisms were recovered from three sets of two blood cultures each. The chest X-ray showed an enlarged cardiac silhouette, but no pulmonary infiltrates were seen. An abdominal ultrasonographic examination showed no evidence of visceral abnormality or abscess formation. The blood pressure rose to 130/70 mm Hg following the administration of intravenous saline. Shortly after admission the temperature rose to 39.1 C. Ampicillin/ sulbactam and aztreonam were given intravenously, but fever persisted for 3 days. As the diagnostic studies had revealed no bacterial infection and the patient had stabilized, the antimicrobials were stopped; her temperature gradually returned to normal. The serum LDH was elevated at 327 p/mL. Serum CPK/isoenzymes, amylase, and transaminase were all normal. The creatinine level returned to 221 pmol/L (2.5 mg/dL). On the sixth hospital day, 3 days after the discontinuation of the antibiotic, a confluent, erythematous, macular rash was noted on her trunk, arms, and hands. All medications except the insulin were discontinued, and the rash subsided. Eight days following her admission she returned to the nursing home. At the nursing home, she returned to her baseline functional status and was able to eat independently. Four days later, her temperature again rose to 39.0 C, and she became lethargic, hypotensive, and oliguric. She was again transferred to the hospital. En route to the hospital, her systolic blood pressure was palpable at 60 mm Hg, and intravenous saline was administered. Upon arrival she responded only to painful stimuli. Her temperature was 37.4 C oral, blood pressure 95/50 mm Hg, pulse 126, and respirations 24.

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TSS IN THE FRAIL ELDERLY

JAGS-MARCH 1992-VOL. 40, NO. 3

CIPROFLOXACIN

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ABBACTAM

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FIGURE 1. A schematic representation of the patient's clinical course.

There was dramatic desquamation of the skin of her palms and soles. Except for the level of consciousness, the neurologic exam had not changed. A comprehensive physical, laboratory and radiologic examination for bacterial infection was again negative. The cervical discharge had persisted, and a culture now grew MRSA. The diagnosis of toxic shock syndrome caused by MRSA was made, and treatment with intravenous vancomycin and oral/nasogastric rifampin was given for 14 days. Follow-up cervical cultures grew no MRSA. Her hospital course was complicated; she failed to regain consciousness and died months later in the nursing home.

DISCUSSION The toxic shock syndrome typically affects young women between the ages of 15 and 25 ears and begins abruptly in association with menses?Although nonmenstrual cases of TSS are well recognized, including cases in which the Staphylococcus uureus was isolated from the vagina, the clinical setting of our case is different from previously reported cases. To the best of our knowledge, after searching Medline (National Library of Medicine) using TOXIC SHOCK SYNDROME, SHOCK-SEPTIC, AGED and NURSING HOMES as key search terms, we were unable to find a case of TSS reported in the frail elderly nursing home resident. The presentation of many illnesses in the frail elderly, particularly infectious diseases, may be subtle and nonspecific.' The reported patient, while only 66 years old, had diabetes mellitus for many years with multiple vascular complications. Because of her diminished functional capacity, she would be considered among the frail elderly by most standards. In our case,

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the early signs and symptoms of TSS, which usually include intense myalgias, fever, vomiting, and diarrhea, were apparently blunted and obscured, or perhaps they were overlooked. Criteria for the diagnosis of TSS include (1) temperature >38.9 C; (2) systolic blood pressure

Toxic shock syndrome in a frail elderly nursing home resident.

~ CLINICAL EXPERIENCE Toxic Shock Syndrome in a Frail Elderlv Nursing Home Resident J Bradley Bowman, MD, and Stephen R. Jones, MD, FACP ever is a...
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