Download Table 1: Diagnostic criteria for toxic shock syndrome

Acta Otorrinolaringol Esp 2005; 56: 376-378
NOTE CLINICAL-SURGICAL
Toxic shock syndrome associated with nasal
packing
J. A. Márquez Moyano, J. M. Jiménez Luque*, R. Sánchez Gutiérrez, L. Rodríguez Tembleque*, P. Ostos
Aumente, J. Roldán Nogueras, P. López Villarejo
Servicio de Otorrinolaringología. *Servicio de Anestesiología y Reanimación. Hospital Universitario Reina Sofía. Córdoba.
Abstract: Staphylococcal Toxic Shock Syndrome is a
potentially fatal multisystem disease, which has been
associated with various surgical procedures related to
nasal packing, catheter insertion, retention of foreign
bodies and breaches in surgical asepsis.
It usually
develops in the first 48 hours following intervention and
includes hypertension, skin rash, fever, and in some cases,
shock and multiorgan failure. We report the case of a 24
year old male patient, who developed the symptoms in the
post-operative period following a septoplasty.
Key words: Toxic shock. Post-operative complications.
Nasal packing. Nasal Surgery.
INTRODUCTION
Toxic
shock syndrome (TSS) represents a
heterogeneous group of infections that produce
hypertension, multiorgan affectation, a characteristic rash
and infection of the soft tissue. It is caused by the exotoxins
and enterotoxins staphylococci or streptococci.
TSS was first described in the 1970s as a syndrome
associated with the use of high absorbency tampons1. It has
subsequently been described as a result of post-operative
infections, burns and viral infections2.
It can often be due to staphylococcal or streptococcal
infection, each with a differentiated clinical presentation
and prognosis.
TSS due to the appearance of the toxin Staphylococcus
aureus in the course of post-operative infections, burns,
immunodeficiencies or cellulitis, is increasing in frequency
in relation to that produced during menstruation. It
Correspondence: Juan Andrés Márquez Moyano.
C/ Río Genil n º 9,,2 º D..14900 Lucena (Córdoba)
E-mail: [email protected]
Fecha de recepción: 8-7-2004
Fecha de aceptación: 24-1-2005
376
normally starts suddenly with high fever, vomiting,
myalgia, migraine and abdominal pain and develops with
a rash (often with diffuse erythrodermia) and erythema on
the palms and soles, normally with desquamation one or
two weeks later. Multiorgan failure normally responds to
treatment, with a mortality rate of approximately 5%3.
Staphylococcal TSS normally involves a fever as the
initial symptom. Myalgia or digestive symptoms are less
frequent. The skin rash is even less common, only
appearing in 10% of patients. Multiorgan affectation is
much more intense with signs of hyperperfusion, acute
renal failure and respiratory distress. The mortality rate
can be between 30-70% of patients3.
We report the case of a 24-year-old male patient, with
no relevant history and with a normal post-operative
study, who was operated on for a septal deviation with
septoplasty. In the post-operative period he developed
symptoms of shock, and was consequently admitted to the
intensive case unit (ICU).
CLINICAL CASE
The patient was a 24-year-old male with no relevant
medical history, with a long evolving history of insufficient
nasal respiration, hardly fluctuating, no seasonal rhythm
and showing little response to local vasoconstrictive and
anti-inflammatory medication. The patient had associated
hyposmia. Physical examination revealed a serious septal
deviation of the vomer, with a blockage of the lumen of the
left nostril. The right inferior turbinate showed a
compensatory hypertrophy that was only slightly reactive
to vasoconstriction. With a diagnosis of nasal septal
deviation, a septoplasty with a right inferior turbinectomy
was proposed and the patient accepted.
The pre-operative study did not show any
abnormality, the clinical, analytical and radiological
examinations all being normal.
The patient was premedicated before going into the
operating room with 1 mg of lorazepam taken
sublingually. After electrocardiogram, indirect arterial
tension and pulse oximetry monitoring, lidocaine (75 mg)
and fentanyl (150 µg) were administered intravenously.
The anesthetic induction was done using propofol
TOXIC SHOCK SYNDROME ASSOCIATED WITH NASAL PACKING
(3mg/kg) and the neuromuscular relaxation was achieved
by using cisatracurium (12 mg). Anesthetic maintenance
was carried out with propofol, fentanyl, and cisatracurium,
keeping the various signs monitored throughout the
operation stable. At the end of surgery the patient was
moved to the resuscitation unit.
The septoplasty was done using Cottle’s technique,
and the intervention was completed with a partial inferior
right turbinectomy. A re-absorbable monofilament suture
was used (Caprosyn®, 3-0); and a sheet of Merocel®,
covered with mupirocine (Bactroban®) antibiotic ointment,
was used to block each nostril.
The patient’s post-operative stay was without incident
except for a slight fever (<37.7°C); the treatment during his
admission included ceftriaxone, paracetamol and ranitidine
taken intravenously. The nasal packing was removed after
48 hours and the patient was discharged.
During the following 24 hours the patient
progressively developed a fever of 41°C and a general
deterioration in his condition. As a result he was taken to
the emergency department of our center, where he was
admitted in a state of shock, with undetectable blood
pressure, acrocyanosis and generalized maculopapular
exanthema. Rhinoscopy showed no purulent collections.
The analysis highlighted metabolic acidosis (pH 7.23),
leukocytosis (32,000 per mm³) and insufficient renal
function (creatinine 9.6 mg/dL). A simple radiological
study of the thorax and abdomen was done as well as
computed tomography of the cranium and paranasal
sinuses, all of which were normal.
The patient was admitted to the ICU where treatment
was set up using fluid therapy, vasoactive drugs and
antibiotic therapy (ceftriaxone + vancomycin). The
hemodynamic situation normalized in the first few hours
with renal function normalizing on the third day. The
patient also presented severe thrombopenic complications
(platelets 15,000 per mm³), with the appearance of
ecchymoses, widespread petechiae, as well as digestive
hemorrhage in the form of melaena, with moderate anemia
(hematocrit 27.3%); a platelet transfusion was made. On the
sixth day of admission to the ICU, the patient was moved,
stable and without consequences, out of the unit to a ward.
It is worth emphasizing that Staphylococcus aureus sensitive
to oxacillin was isolated in the culture from the nasal
smear. An immunological study was done, which did not
confirm any cellular or humoral immunodeficiency.
Throughout the second week of evolution there was
desquamation of the entire body surface, including the
palms and soles. Fourteen days after admission to the ICU,
the patient was discharged with a diagnosis of
Staphylococcal Toxic Shock.
Following the protocol for septic shock, intravenous
vancomycin was maintained for fourteen days. The
antibiotic treatment was completed with five days of oral
cloxacillin administered in the patient’s home.
The patient continued to be monitored during external
ENT and internal medicine consultations and six months
after the episode remains without any abnormalities.
Subjective nasal function is satisfactory.
DISCUSSION
TSS is a rare syndrome that can complicate the
patient’s post-operative period, triggering a lifethreatening medical situation. Although the classic form of
appearance is related to the use of high absorbency
tampons, its appearance during the post-operative period
following ENT, abdominal or trauma surgery4 is becoming
more common.
TSS can occur in any surgical procedure which uses
catheters, nasal packing, or any other device which can be
favorable to the growth of pathogenic organisms. Its
appearance after nasal surgery has been described in the
first 24-48 hours following intervention. This intervention
presents the greatest risk in the mucous membrane, a
location which is often colonized by Staphylococcus aureus.
One can add as favorable factors surgical injury to the
mucous and placing nasal packing during the immediate
post-operative period4-6. Jacobson and Kasworm calculate
the incidence of infection as 16.5 cases for every 100,000
patients undergoing nasal surgery in the population of
Utah7. Although the relationship has been proved, useful
underlying factors or efficient methods of prevention have
not been identified8,9. There are authors who have studied
the incidence of the syndrome according to the type of
nasal packing, comparing expandable packing with edged
gauze. The number of patients in the samples is few and
there do not appear to be significant differences10. On the
other hand, Younis and Lazar describe five cases of late
TSS (between 5 and 35 days) in nasal surgery without postoperative packing11.
Therefore, TSS is a syndrome which must be
considered in patients undergoing surgery, especially
trauma or ENT, who experience high fever, hypertension
and multiorgan failure in the first few days of the postoperative period. The dermatological symptoms may be
another element which helps in the diagnosis of these
patients12.
The symptoms can point to the staphylococcal or
streptococcal form depending on the severity of the
multiorgan failure, the dermatological symptoms or the
intensity of the digestive symptoms and myalgias. The
final diagnosis can only be established by isolating the
germs responsible and by determining the toxins3.
In our patient the history of ENT surgery, the
exanthema which affected the palms and soles and the
clinical symptomatology pointed towards a staphylococcal
origin of the symptoms. The patients complied with the
seven necessary diagnostic criteria described for the
definition of TSS13 (Table 1). The evolution of the
symptoms and the response to treatment also coincide with
the staphylococcal form of TSS.
377
J. A. MÁRQUEZ MOYANO ET AL.
Table 1: Diagnostic criteria for toxic shock syndrome
DEFINITE TSS
PROBABLE TSS
•
•
•
•
•
•
•
•
•
•
•
•
Temperature >38°C.
Widespread diffused generalized maculopapular rash.
Flaking of the palms and soles 7 to 14 days after the
onset of symptoms.
Hypertension.
− Systolic pressure <90mmHg.
− Orthostatic pressure: falling 20 mm Hg.
− Syncope or orthostatic vertigo.
Clinical or analytical anomalies of three or more organic
systems.
Reasonable evidence of absence of other causes.
The associated high morbi-mortality, the characteristic
clinical presentation and the appearance within the first
few days of the post-operative period mean that intensive
antibiotic treatment has to be established along with
cardiocirculatory support for those patients in whom TSS is
suspected. High dose corticotherapy has been used and
appears to reduce the severity and duration of the
infection14. The success of the treatment lies in the early
diagnosis and the rapid establishment of means of support.
•
•
Temperature >38°C.
Rash.
Hypertension, syncope or orthostatic vertigo.
Myalgias.
Vomiting and/or diarrhea
Inflammation of the mucous membrane (conjunctivitis,
pharyngitis, vaginitis).
Clinical or analytical anomalies of three or more organic
systems.
Reasonable evidence of absence of other causes.
7.
8.
9.
10.
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2.
3.
4.
5.
6.
378
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