profound hypotension, desquamation,and multisystem involvement
(including vomiting or diarrhea, severe myalgias, mucus membrane hyper-
emia, renal or hepatic dysfunction, decreased platelets, and disorientation).
TSS can rapidly progress to multisystem dysfunction and shock. TSS was
initially recognized as a disease of young, healthy, menstruating women, in
which tampon use increased the risk 33 times. With increased awareness
and changes in tampon composition, cases of TSS have declined over the
past 20 years. Staphylococcus aureusis the causative organism. An exotoxin
produced by S aureusis the presumed cause in menstrual-related TSS
(MRTSS) and two endotoxins have been implicated in non–menstrual-
related TSS (NMRTSS). TSS should be considered in any unexplained
febrile illness associated with erythroderma, hypotension, and diffuse
organ pathology. Patients with MRTSS usually present between the third
and fifth day of menses. In severe cases, headache is the most common
complaint. The rash is a diffuse, blanching erythroderma, often described
as a painless “sunburn” that fades within 3 days and is followed by desqua-
mation, especially of the palms and soles. For severe cases, treatment
includes aggressive IV fluid resuscitation, IV oxacillin or cefazolin, and
hospital admission in a monitored setting.
(b)Rocky Mountain spotted fever (RMSF) is caused by R rickettsii,
which is transmitted by ticks. The organism multiplies in endothelial cells
lining small vessels, causing generalized vasculitis as well as headache,
fever, confusion, rash, myalgias, and shock. The rash usually appears on
day 2 to 3, initially on the wrists, ankles, palms, and soles, spreading
rapidly to the extremities and trunk. Lesions begin as small, erythematous
blanching macules that become maculopapular and petechial. The location
and type of rash, along with the history distinguish RMSF from TSS. Serologic
tests are confirmatory, but treatment with doxycycline or chloramphenicol
should be started prior to confirmation. (c)Streptococcal scarlet fever
is an acute febrile illness primarily affecting young children, caused by
S pyogenes(group A streptococci [GAS]). The “sandpaper” rash of scarlet
fever differs from the macular sunburn rash of TSS. The treatment is peni-
cillin or a macrolide in penicillin-allergic patients. While S aureusis the
causative organism of TSS, a less common, but more aggressive, TSS-like
syndrome, streptococcal TSS (STSS), has recently emerged. The treatment
is similar to TSS, with aggressive fluid management along with IV penicillin
and clindamycin. These patients may progress to a necrotizing fasciitis or
myositis, requiring surgical intervention. (d)Meningococcemia is an infec-
tious vasculitis caused by disseminated N meningitides,a gram-negative
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