Toxic shock syndrome: a silent killer.

We present a case of a 27-year-old para 2þ 0 who had a normal delivery 2 years previously. She had a previous cone biopsy for CIN3 and was receiving annual smears. She was referred by her GP to our A&E department with a 24 h history of generally feeling unwell, with diarrhoea, vomiting and lower abdominal pain. Her temperature was 388C; she was hypotensive (blood pressure 72/ 38 mmHg), with a respiratory rate of 15. Systemic examination did not reveal any significant findings except mild suprapubic tenderness. A provisional diagnosis of septicaemia was made, but the focus of infection was unknown. Investigations performed included FBC, coagulation screen, blood cultures, ECG, U&E, CRP, showed raised inflammatory markers (WCC 22, CRP 249); clotting profile was deranged (PT 17.9 APTT42.9). There was hyponatremia, hyperkalemia, elevated uric acid and creatinine level. Serum bHCG, ECG and blood glucose results were normal. In view of the acute presentation, she was transferred to our ICU. She was started on intravenous Cefuroxime, gentamycin and aggressive fluid resuscitation. A gynaecological opinion was sought to review her tender and erythematous vulva, which was noted during the process of catheterisation. Vaginal examination revealed a tampon, which was sent for culture and sensitivity. She recollected the tampon to be in situ for 48 h. The tampon and the swabs grew Staphylococcus aureus. A diagnosis of toxic shock syndrome (TSS) was made. Flucloxacillin was added to her treatment regime and she made an adequate recovery within 24 h. On follow-up 2 weeks after discharge, she seemed well with no obvious sequelae.