A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4.
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August 22, 2017 at 8:32 am
C.
The most likely diagnosis is toxic shock syndrome, and aggressive resuscitation and PICU admission is indicated
The patient has signs of shock: tachycardia and hypotension. Streptococcal toxic shock syndrome is associated with soft tissue infections, often presenting with pain out of proportion to physical exam initially. Risk factors include recent GAS infection (eg pharyngitis), minor trauma, recent surgery, varicella, NSAID use, being postpartum. In contrast to Staphylococcal toxic shock syndrome, which is associated with tampon use and trauma & surgery/procedures, diffuse erythroderma sunburn-like rash is seen in only 10%. Common lab abnormalities are: left shift on CBC WBC, elevated creatinine, thrombocytopenia, and elevated transaminases and total bilirubin. Influenza is associated with an increased risk of associated septic shock, and can also lead to a myocarditis and cardiogenic shock. Influenza can also cause a myositis, but would not expect shock, left shift of WBC, and early acute renal failure.