[Toxic shock syndrome with multi-organ involvement]

An 18-year-old school girl was referred for admission by another hospital because of headache, joint pains, fever, vomiting, diarrhoea and orthostatic syncope associated with renal failure. On admission he was somnolent with a blood pressure of 90/60 mmHg, heart rate of 104 beats/min and a slight fever of 39.1 degrees C. A sunburn-like skin rash was noted.

Laboratory tests indicated low levels of platelets and calcium, increased levels of white cells, C-reactive protein, creatinine, bilirubin, transaminases, creatinekinase and lactate. Chest X-ray demonstrated diffuse shadows, while other imaging revealed a space-occupying lesion, ca. 3 cm in diameter, in the right lowere quadrant of the abdomen. The patient was hypoxic. Microbiology revealed vaginal colonies of Staph. aureus (producing toxic shock syndrome toxin 1 [TSST-1]). Serum antibody titre against TSST-1 was less than 1:25.

A toxic shock syndrome (TSS) with multi-organ involvement was suspected because of the association of menstruation with the use of tampons. An inserted tampon was removed. At laparoscopy the space-occupying lesion proved to be a haematoma. As bacterial septicaemia could not ne excluded broad-spectrum antibiotics were administered together with symptomatic measures. The patient fully recovered within a week. The characteristic skin desquamation confirmed the diagnosis of TSS.

In its acute phase the diagnosis of TSS is often uncertain. The initial symptoms are nonspecific and numerous conditions need to be considered in the differential diagnosis. The diagnosis can be confirmed, if at all, only in the convalescent phase by the skin desquamation or a rise in anti-TSST-1 antibody titre. A search for a focus of infection is essential for differentiation from a non-menstrual TSS, even if there is as association with menstruation.