Toxic Shock Syndrome Following Influenza -- Oregon; Update
on Influenza Activity -- United States
Oregon. A case of toxic shock syndrome (TSS) following
influenza
has been reported to CDC. On December 11, 1986, a 13-year-old
white
female with fever, hypotension, and acute respiratory failure was
seen
at an Oregon hospital. Pertinent findings on physical examination
included a temperature of 39 C (102 F); blood pressure of 60/0;
evidence of upper airway obstruction; and conjunctival, palatal,
and
lingual hyperemia. A chest radiograph at the time of admission
showed
a bilateral increase in lung markings consistent with a diagnosis
of
early adult respiratory distress syndrome.
During the 24 hours following admission, the patient developed
a
diffuse, erythematous, sunburn-like rash and watery diarrhea. She
required both intravenous fluids and vasopressors for treatment of
severe hypotension. A diagnosis of toxic shock syndrome was
considered and was supported by laboratory findings of
thrombocytopenia (70,000/mm((3))), renal insufficiency (creatinine
level = 2.8 mg/dL, urea nitrogen level = 40 mg/dL), hypocalcemia
(Ca =
5.9 mg/dL), and elevated levels of creatine kinase (12,000 U/L) and
aspartate aminotransferase (367 U/L). Staphylococcus aureus was
isolated from two tracheal aspirates obtained on the day of
admission. Other studies, including vaginal cultures, blood
cultures,
and urine antigen testing, were negative for pathogenic organisms.
Although the patient's menstrual cycle had begun 6 days before
admission, she had not used tampons or other intra-vaginal devices
and
was not sexually active. However, she had a history of a 4-day
prodrome of an influenza-like illness consisting of fever
(temperature
=40 C (104 F)), malaise, myalgias, sore throat, and substernal
chest
discomfort.
The patient was discharged following a 10-day hospitalization.
On
a follow-up examination 20 days after admission, full thickness
desquamation of the palms and soles was noted. Testing of acute-
and
convalescent-phase sera revealed a rise in
hemagglutination-inhibition
antibody titer to influenza A(H1N1) from 32 on December 13 to 1,024
at
the time of her follow-up examination on December 31.
United States. Outbreaks of type A(H1N1) influenza activity
are
continuing. For the week ending January 31, six western states*
and
Puerto Rico reported widespread outbreaks of influenza-like
illness,
and 19 states** and the District of Columbia reported regional
outbreaks of influenza-like illness. This is the sixth week with
more
than 20 states reporting outbreak activity. The level of current
activity is below the peak of the previous winter when 37 states
reported outbreaks for 1 week in February.
Reported by M Brooks, MD, P Bennington, Northwest Kaiser
Permanente, D
McNeill, Oregon Public Health Laboratory, D Fleming, MD, LR Foster,
MD, State Epidemiologist, State Health Div, Oregon Dept of Human
Resources; State and Territorial Epidemiologists and State
Laboratory
Directors; Meningitis and Special Pathogens Br, Div of Bacterial
Diseases, WHO Collaborating Center for Influenza, Influenza Br, Div
of
Viral Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note:This 13-year-old girl's illness meets the case
definition for TSS (1), which is caused by toxin-producing S.
aureus
in a susceptible host. The temporal relation between the child's
illness and menstruation is most likely coincidental since no S.
aureus was isolated from the vagina. The S. aureus isolated from
the
tracheal aspirates is the most likely cause of TSS in this patient.
TSS associated with S. aureus respiratory infections has been
reported
previously (2). TSS following influenza was first reported last
year
during an epidemic of influenza type B (3). This is the first case
of
TSS following influenza reported to CDC this year and the first
case
reported following influenza type A(H1N1).
The occurrence of TSS following influenza may be coincidental,
but
S. aureus pneumonia as a complication of influenza is well
documented
(4,5). Physicians are encouraged to obtain cultures and serologies
for influenza in cases of TSS following influenza-like illness or
during influenza epidemics. Physicians who have seen patients with
TSS following influenza-like illness are encouraged to report these
cases through their local and state health departments to the
Meningitis and Special Pathogens Branch, Division of Bacterial
Diseases, Center for Infectious Diseases, CDC, Atlanta, Georgia
30333;
telephone (404)329-3687.
References
Chesney PJ, Davis JP, Purdy WK, Wand PJ, Chesney RW. Clinical
manifestations of toxic shock syndrome. JAMA 1981;246:741-8.
Wilkins EGL, Nye F, Roberts C, de Saxe M. Probable toxic shock
syndrome with primary staphylococcal pneumonia. J Infect
1985;11:231-2.
CDC. Toxic shock syndrome associated with
influenza--Minnesota.
MMWR 1986;35:143-4.
Schwarzmann SW, Adler JL, Sullivan RJ Jr, Marine WM. Bacterial
pneumonia during the Hong Kong influenza epidemic of 1968-1969:
experience in a city-county hospital. Arch Intern Med
1971;127:1037-41.
Loosli CG. Influenza and the interaction of viruses and
bacteria
in respiratory infections. Medicine 1973;52:369-84.
*Alaska, Idaho, Oregon, Texas, Washington, and Wyoming.
**Alabama, Arizona, Arkansas, California, Connecticut, Iowa,
Kansas,
Kentucky, Minnesota, Mississippi, Missouri, Nebraska, New Mexico,
North Carolina, North Dakota, Pennsylvania, South Carolina, South
Dakota, and Wisconsin.
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