Case In Point
Staphylococcal Toxic Shock Syndrome From Methicillin-Susceptible Staphylococcus aureus Septic Costochondritis
Christopher Kuo, MD
Division of Infectious Disease, Department of Pediatrics, Rush University Medical Center, Chicago, Illinois, and Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
Kuo C. Staphylococcal toxic shock syndrome from methicillin-susceptible Staphylococcus aureus septic costochondritis. Consultant. 2019;59(5):137-139.
A 17-year-old, previously healthy, athletic adolescent boy presented to the emergency department (ED) with fever, nausea, general malaise, fatigue, abdominal pain, and sore throat for 1 day. Two weeks prior, the patient had sustained a left shoulder injury during a basketball game.
Physical examination. In the ED, the patient’s vital signs were as follows: blood pressure, 104/49 mm Hg; pulse, 126 beats/min; temperature 39.2°C; respiratory rate, 34 breaths/min; and oxygen saturation, 97% on room air. Physical examination revealed an ill-appearing adolescent with posterior oropharyngeal erythema, mild cervical lymphadenopathy, and marked left costochondral junction and abdominal tenderness upon palpation.
Diagnostic tests. Notable results of laboratory investigations were as follows: white blood cell (WBC) count, normal at 8580/µL but with a high neutrophil fraction of 93.8%; hemoglobin, normal at 14.5 g/dL; platelet count, low normal at 152 × 103/µL; aspartate transaminase, elevated at 58 U/L; alanine transaminase, elevated at 95 U/L; prolonged prothrombin time/partial thromboplastin time (international normalized ratio, 1.75; activated partial thromboplastin time, 33.6 s); conjugated hyperbilirubinemia (total bilirubin, 7.4 mg/dL; direct bilirubin, 3.7 mg/dL); albumin, normal at 3.6 g/dL; lipase, normal at 11 U/L; and C-reactive protein (CRP), elevated at 78.5 mg/L (reference range, 0-8 mg/L).
Additional workup included electrocardiography, which showed ST-segment elevation in the anterolateral lead, and chest radiography, the findings of which were unremarkable. The troponin level (0.01 ng/mL) and creatine kinase level (107 U/L) were normal.
Results of a rapid streptococcal antigen test, respiratory pathogen polymerase chain reaction (PCR), throat culture, routine fungal culture, antistreptolysin O titer, Epstein-Barr virus PCR, cytomegalovirus PCR, hepatitis A/B/C panel, and HIV antigen/antibody/RNA were all negative. Blood cultures were obtained, and he was resuscitated with 2-L normal saline boluses.
Computed tomography (CT) scan of the abdomen and pelvis showed pericolonic inflammatory fat stranding and an unremarkable liver. Ultrasonography of the abdomen showed splenomegaly and a septate hepatic cyst with no evidence of gallstones.