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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. References 1. 2. 3. 4. 5. 6. 378 Tood J, Fishaut M, Kapral F, Welch T. Toxic-shock syndrome associated with phage-group I staphylococci. Lancet 1978;1:1116-1118. Jones J, MacRae DL. Toxic shock syndrome. J Otolaryngol 1990;19(3):211-213. Dellaripa PF.Toxic shock syndrome. J Intensive Care Med 2000;15(6):314-320. Allen ST, Liland JB, Nichols CG, Glew RH. Toxic shock síndrome associated with use of latex nasal packing. Arch Intern Med 1990;150(12):2587-2588. Keller JL, Evan KE, Wetmore RF. Toxic shock syndrome after closed reduction of a nasal fracture. Otolaryngol Head Neck Surg 1999;120:569-570. Mansfield CJ, Peterson MB. Toxic shock syndrome : 11. 12. 13. 14. associated with nasal packing. Clin Pediatr 1989;28(10):443-445. Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal surgery. Case report and analysis of risk factors. Arch Otolaryngol Head Neck Surg 1986;112(3):329-32. de Vries N, van der Baan S. Toxic shock syndrome after nasal surgery: is prevention possible? A case report and review of the literature. Rhinology 1989;27(2):125-128. Jacobson JA, Stevens MH, Kasworm EM. Evaluation of a single-dose cefazolin prophylaxis for toxic shock syndrome.Arch Otolaryngol Head Neck Surg 1988;114:326-327. Breda SD, Jacobs JB, Lebowitz AS, Tierno PM Jr. Toxic shock syndrome in nasal surgery: a physiochemical and microbiologic evaluation of Merocel and NuGauce nasal packing. Laryngoscope 1987;97(12):1988-1391. Younis RT, Lazar RH. Delayed toxic shock syndrome after functional endonasal sinus surgery. Arch Otolaryngol Head Neck Surg 1996;122(1):83-85. Odom SR, Stallard JD, Pacheco HO, Ho H. Postoperative staphylococcal toxic shock syndrome due to pre-existing staphylococcal infection: case report and review of the literature. Am Surg 2001;67(8):745-747. Tofte RW, Williams DN. Toxic shock syndrome: evidence of a broad clinical spectrum. JAMA 1981;246(19):21632167. Todd TK, Rossman M, Castor SA, Todd BH, Wiesenthal AM. Corticosteroid therapy for patients with toxic shock syndrome. JAMA 1984;252(24):3399-3402.