A 33‐year‐old G1P1 breastfeeding woman was admitted for hypotension and rash 3 days after suslaining a possible infant bite to the right nipple. She developed pain followed by expanding skin breakdown and erythema on the right breast. The erythema spread despite increased breast pumping and hot compresses. A diagnosis of mastitis was made in the urgent care clinic, and dicloxacillin and ibuprofen were prescribed. Several hours later the patient developed nausea, vomiting, diarrhea, fevers, and chills. On presentation to the emergency department, she had a systolic blood pressure of 50, a heart rate of 120, generalized erythema, and conjunctival injection. The right breast was erythematous, warm, indurated, and tender Laboratory abnormalities included: while blood cell count 24.7, INR 19, creatinine 4.1, lactate 5, and bilirubin 4.8. Initial differential diagnosis included Staphylococcal toxic shock syndrome (TSS), sepsis, and drug reaction. The patient was admitted to the intensive care unit and treated aggressively with fluids, vasopressors, and broad‐spectrum antibiotics. Clindamycin was initiated specifically for TSS. Blood cultures were negative, and she improved rapidly. The patient was discharged home to complete a course of clindamycin.
This patient demonstrated the classic signs of TSS, with rapid symptom onset and profound hypotension caused by toxin (TSST‐1)–mediated massive cytokine release. Diagnostic criteria include SBP < 90 and symptoms of orthostasis or an orthostatic change in BP of > 15 mm Hg. The erythroderma can vary but often involves the palms and soles. Mucosal surfaces are frequently involved, including the conjunctival injection seen in this patient. As in our patient, involvement of 3 or more organ systems is a diagnostic criterion. The patient was treated with clindamycin because of in vitro evidence demonstrating decreased toxin production with protein synthesis inhibitors such as clindamycin or linezolid. Mastitis has been described as a cause of nonmenstrual TSS, though largely in the European literature. Of the described cases, both methicillin‐sensitive and methicillin‐resislant Staphylococcus aureus were represented.
The hospitalist is frequently faced with a febrile, hypotensive patient. The differential diagnosis must remain broad so as not to miss a less common diagnosis as in this case involving a postpartum, breastfeeding woman. Because bacteria have multiple ways of causing illness, including toxin production, overwhelming disease can develop from small or superficial foci of infection such as mastitis. If TSS is on the differential, clindamycin or another inhibitor of protein synthesis should be added to the initial antibiotic regimen.
A. Green, none; E. Moseson, none; H. Win, none.