Differential Diagnosis
- Kawasaki disease
- Leptospirosis
- Rocky Mountain spotted fever
- Toxic shock syndrome
Diagnosis
The correct diagnosis in this case is toxic shock syndrome (TSS), a severe exotoxin-mediated bacterial infection that is characterized by the acute onset of high fever, headache, conjunctival injection, erythema of the pharynx, vomiting, diarrhea, and hypotension. Two subtypes of TSS are defined by the bacterial etiology: Staphylococcus aureus; and group A streptococci. Patients with mild disease may rapidly progress to shock and organ failure.
In the 1980s, staphylococcal TSS most affected menstruating young White females using tampons, however, increased public education and the discontinuation of high-absorbency tampons has led to a decline in menstrual TSS cases since. Current staphylococcal TSS cases are seen in postsurgical interventions, burn patients, patients with dialysis lines, and those with nasal packing following nasal surgery, as in this case.
What to Look For
- Dermatologic manifestations of staphylococcal TSS include: diffuse erythematous patches that begin on the trunk and spread toward the extremities; erythema and swelling of the palms and soles with or without generalized nonpitting edema; desquamation of the palms and soles usually 1-3 weeks after the initial onset of the rash; and erythema of the mucous membranes (strawberry tongue and conjunctival hyperemia)
- Laboratory examination may show leukocytosis, bandemia, elevated blood urea nitrogen, and elevated creatinine
Pearls for Urgent Care Management
- As this is a life-threatening condition, management includes immediate and rapid transfer to the emergency department for stabilization
- If available, IV fluids should be initiated while awaiting transport