sign in sign up
<<
Home , Scarlet fever, Toxic shock syndrome

Postgrad Med J: first published as 10.1136/pgmj.64.758.965 on 1 December 1988. Downloaded from Postgraduate Medical Journal (1988) 64, 965-967

Scarlet can mimic toxic

M.G. Brook and B.A. Bannister Royal Free Hospital Department of Infectious Diseases, Coppetts Wood Hospital, Coppetts Road, London NJO JJN, UK.

Summary: We describe a patient who presented with a widespread erythematous , diarrhoea, , pre-renal uraemia and hyponatraemia. The diagnosis of staphylococcal seemed likely as she was menstruating and there was no evidence of pharyngitis. A rising ASO titre confirmed a streptococcal aetiology and thus 'toxic' . Toxic shock syndrome and toxic scarlet fever are compared.

Introduction Scarlet fever was a major cause of morbidity and later because of tongue swelling. Two days before mortality in the pre- era. Although the admission she became confused, anuric, had hic- term toxic shock syndrome has become synony- coughs and abdominal distension. had Protected by copyright. mous with a staphylococcal related illness of rash been used from 3 days prior to the onset of the and , such features would far more illness until admission. likely have had a streptococcal aetiology in the On examination she was apyrexial, confused, earlier part of this century.1 - 3 Scarlet fever still disorientated and incoherent. There was a diffuse occurs, but the disease seen nowadays is usually no erythematous rash affecting the whole of the body, more severe than an uncomplicated streptococcal with peeling on the face, and petechiae and ecchy- with the addition of a rash.4 It is moses over the anterior lower limbs. There was unclear why the severe toxic form of the disease has neck stiffness but neurological examination was become uncommon, but its incidence fell simulta- otherwise normal. There were no obvious sites of neously with that of the other streptococcal compli- skin . The oropharynx was diffusely cations: and .1 inflamed but the tonsils were not swollen and there Patients, particularly adult females, presenting with was no exudate. There was minimal uterine bleed- a severe illness associated with an erythematous ing, a mildly inflamed cervix and a small amount of

rash would nowadays be most likely diagnosed as maladorous discharge. There was no pelvic tender- http://pmj.bmj.com/ toxic shock syndrome (TSS).5-10 We present such ness or induration. The was 115/ a case which highlights the diagnostic pitfalls and 75mmHg with a pulse of 100 beats/min. shows that 'toxic' scarlet fever (TSF) has not Initial investigations revealed uraemia (urea completely disappeared. The clinical similarities 23.8 mmol/l, creatinine 436 jumol/l, potassium between TSS and TSF are also reviewed and 4.6 mmol/l and urinary sodium 5 mmol/l), hypona- features of differentiation are stressed. traemia (1 13 mmol/l), hypocalcaemia (1.92 mmol/l) and hypoalbuminaemia (26 g/l) and biochemical

evidence of myositis. The electrocardiogram was on September 28, 2021 by guest. Case report normal. There was mild anaemia (10.7g/1) with a leucocytosis (neutrophils 27x 109/l) and thrombo- Seven days prior to admission a 40 year old cytopaenia (90 x 109/l), but disseminated intravascu- married school teacher suddenly became ill with lar coagulation was excluded by normal clotting abdominal pain and diarrhoea. On the third day of studies and absent fibrin degradation products. illness a widespread erythematous rash, a tempera- function tests, cerebrospinal fluid, urine mic- ture of 41°C and developed. was roscopy and urinalysis were normal. commenced but changed to one day Initial antibiotic treatment was with Correspondence: M.G. Brook, B.Sc., M.R.C.P., and cefotaxime, and her initial recovery was rapid D.R.C.O.G., D.T.M.&H., D.C.H. but later complicated by a gastrointestinal haemorr- Accepted: 5 July 1988 hage, fluid retention related to hypoalbuminaemia ©) The Fellowship of Postgraduate Medicine, 1988 Postgrad Med J: first published as 10.1136/pgmj.64.758.965 on 1 December 1988. Downloaded from 966 CLINICAL REPORTS and ileus. She was discharged fit and well 4 weeks predominance. The incidence of hypotension, renal after admission, with all laboratory tests normal. failure and hepatic dysfunction in TSF is unclear as Pathogenic organisms were not cultured from there are few descriptions in recent literature' and multiple swabs, presumably due to prior antibiotic accounts from earlier in the century use non- treatment, and no site of infection was found, but a specific terms such as 'toxaemia' and 'collapse'. rising ASO titre from 200-400IU/ml on admission These complications are common in TSS5-10 and to 3200IU/ml at 4 weeks confirmed the diagnosis their presence would also suggest the latter of toxic scarlet fever. The anti-staphylococcal diagnosis. , anti-staphylolysin and anti-nuclease, Laboratory data on TSF are sparse as most remained stable in low titres. published accounts were written from the pre- antibiotic era.I-3 A recent report of two cases of atypical TSF suggests that hepatic and renal dys- Discussion function does occur" whereas these complications are well recognized in TSS.'-10 Although altered Before the ASOT titre rise, the aetiological diagno- muscle enzymes have not previously been reported sis was unclear. This emphasizes the considerable in TSF, the frequent description of clinical myositis overlap between TSS and TSF. There were several suggests that this test would be abnormal with features not typical of scarlet fever, including a lack similar frequency in both conditions. Myocarditis is of evidence of focal streptococcal infection in spite seen in up to 20% of cases of scarlet fever and of attempts to isolate pyogenes from would also cause increased muscle enzymes.' Disse- throat, vagina and . Similarly, the uraemia, minated intravascular coagulation has also been hyponatraemia and diarrhoea seen in this patient reported in both TSS and TSF."7"';' Features that have been rarely reported in TSF11 although would suggest TSS and not TSF include hypoten- glomerulonephritis is a recognized late complica- sion and diarrhoea.5-'0 Diarrhoea has only been Protected by copyright. tion.5 It is possible that a low grade septicaemia described as a rare pre-terminal of had occurred in this patient and had responded to TSF1 but has also been reported in severe strepto- the given at home. This might then coccal including septicaemia. 12 - 14 explain the diarrhoea and pre-renal uraemia.12 -14 use and vagino-cervicitis are features of The reported clinical features common to TSS over 90% of cases of TSS,5-10 although menstrua- and TSF include a widespread erythematous rash tion may be a non-causal coincidental association which later peels, headache, , mucosal of TSF, as seen in the patient described. inflammation, confusion and myalgia. I-0 This is In cases of infection originating outside the perhaps not surprising as the pyogenic toxin type A throat and vagina the initial diagnosis can be produced by scarlet fever-related strains of strepto- difficult, particularly in the common situation cocci, and toxic shock syndrome toxin type I where the pre-admission use of antibiotics has (TSST-1) produced by staphylococci isolated in prevented the early identification of organisms. The cases of TSS have a similar structure. 1"" 16 The implication of this overlap is that anti- mortality of TSF is unknown but is likely to be staphylococcal antibiotics such as flucloxacillin or similar to the presently reported 5% for TSS.' fusidic acid may be used after an incorrect diagno- http://pmj.bmj.com/ Both diseases can occur following skin infec- sis of TSS, and would provide suboptimal cover tions' 4,17 although TSF most commonly occurs against streptococci. Benzylpenicillin is the drug of as a complication of pharyngitis/' -4 and choice for streptococcal infection, and therefore TSS in association with vaginitis during menstrua- TSF, but may be ineffective for up to 80% of tion following tampon use.5-10 The other clinical staphylococcal isolates.'8 At a time when TSS is in features that would suggest TSF in cases of uncer- the forefront of medical literature8 and TSF tainty include puncta and skin crease accentuation thought to have virtually disappeared,5 TSF should on September 28, 2021 by guest. of the (Pastia's sign). Illness in a male be remembered in cases of 'atypical' TSS and would also suggest TSF in a disease that has an antibiotic prescribing should be accordingly equal sex incidence, whereas TSS has a 9:1 female adapted.

References 1. Dick, G.F. & Dick, G.H. Symptoms. In: Scarlet 3. Dowling, H.F. Streptococci infections. In: The Acute Fever. The Year Book Publishers, Chicago, 1938, pp Bacterial Diseases. W.B. Saunders, London, 1948, pp 35-52. 34-172. 2. Musser, J.H. Scarlet fever. In: Pullen, R.L. (ed) 4. Breese, B.B. Streptococcal pharyngitis and scarlet Communicable Diseases. Henry Kimpton, London, fever. Am J Dis Child 1978, 132: 612-616. 1950, pp 69-79. Postgrad Med J: first published as 10.1136/pgmj.64.758.965 on 1 December 1988. Downloaded from CLINICAL REPORTS 967

5. Christie, A.B. Toxic shock . In: Infectious 13. Thomas, P.S., Wilkins, E. & Hickey, M. Streptococ- Diseases. Churchill Livingstone, London, 1987, pp. cus pyogenes and dysentery. J Infection 1988, 16: 12-16. 200-201. 6. Todd, J., Fishaut, M., Kapral, F. & Welch, T. Toxic- 14. Ispahani, P., Donald, F.E. & Avelio, A.J.D. Strepto- shock syndrome associated with phage-group- 1 coccus pyogenes bacteraemia: an old enemy subdued Staphylococci. Lancet 1978, ii: 1116-1118. but not defeated. J Infection 1988, 16: 37-46. 7. Shandos, K., Schmid, G.B., Bruce, D.B. et al. Toxic 15. Willoughby, R. & Greenberg, R.N. The toxic shock shock sundrome in menstruating women. N Engl J syndrome and streptococcal pyrogenic . Ann Med 1980, 303: 1436-1442. Intern Med 1983; 98: 559. 8. Eykyn, S.J. Toxic shock syndrome. Some answers but 16. Johnson, L.P., L'Italien, J.J. & Schlievert, P.M. Strep- questions remain. Br Med J 1982, 284: 1585-1586. tococcal pyrogenic type A (Scarlet fever 9. Neild, G. & Cameron, J.S. Tampon shock. Lancet toxin) is related to enterotoxin 1980, ii: 1196. B. MGG 1986, 203: 354-356. 10. Anon. Toxic shock and tampons. Br Med J 1980, 281: 17. Rengold, A.L., Dan, B.B., Shandds, K.K.N. & 1426. Broome, C.V. Toxic shock syndrome not associated 11. Cone, L.A., Woodare, D.R., Schlievert, P.M. & with menstruation. Lancet 1982, i: 1-4. Timory, G.S. Clinical and bacteriologic observations 18. Phillips, I. & Eykyn, S.J. Staphylococci. In: of a toxic shock-like syndrome due to Streptococcus Weatherall, D.J., Ledingham, J.G.G. & Warrell, D.A. pyogenes. N Engl J Med 1987, 317: 146-149. (eds) The Oxford Textbook of Medicine, vol. 2. 12. Teall, A., Visuvanthan, S., Payne, A. & Silverstone, Oxford Medical Publications, Oxford, 1987, 5: A. Unsuspected streptococcal infection presenting 191-198. with diarrhoea in late pregnancy. J Infection 1987, 14: 185-186. Protected by copyright. http://pmj.bmj.com/ on September 28, 2021 by guest.