- Email: [email protected]
Toxic Shock Syndrome Following Ureterolithotomy
0022-5047 /82/=_28f ,~3~)5$0~.00/0 ~HE
,rol. 128, Decernber Printed ir,, U.S.A.
CF
Copyiigbt © 1982 by The ·\iVillia.ms & Wilkins
STEPHEN R
CHARLES D. CAPP
AND
DAVID VV. FERGUSON
From the Urology and Medical Services, Mercy Medical Center, Redding, California
ABSTRACT
Toxic shock syndrome is a much p~,u,.,~,.~~ disease that has been '°"'""'n.",-'°',.., most often in female who use tampons. It has been linked to infection with certain strains of staphylococci. We describe the first case, of which we are aware, of this as a e,uu11uu...,a.ue,,u of urologic surgery. A man underwent an uncomplicated right mid ureterolithotomy on June 3, 1981 for a 4 X 7 mm. calcium oxalate calculus. The urine was sterile and the immediate postoperative course was unremarkable. Urine drainage was moderate until 3 days postoperatively, when it ceased and the Penrose drain was removed. At 5 days 1xistoper,at1veJ the patient was afebrile with a white blood count he was discharged from the hospital. The next experienced chills ar,d and nausea, vomiting and diarrhea. Physical examination disclosed a ill man who was delirious. Temperature was 102.GF and blood pressure was 84/ 34 mm. Hg. The rate was 120 per minute and difficult to palpate. The were and there v,as a confluent, bright red truncal rash that blanched on pressure. The sclera was injected and the tongue was dry but otherwise unremarkable. There was no pharyngitis. The chest was clear and auscultation of the heart reveaied a sinus n½"nn=," but or rubs. Abdominal examination was unflank incision had no evidence of wound infection. Neuxologic examination disclosed disturbed mentation but no lateralizing findings. The remainder of the w, n,1u~.1 examination was unremarkable. The white blood count was 17,400 with 75 3 monocytes. The 20 2 1y,.111-1uc,1..,i uc,uv,,..,v,nH was 14.9 gm. were normal except for a low serum calcium of 7.0 mg./dl. Bbod urea n,·t-rr,rre,r, was 43 and creatinine was 4.6 mg./dL Liver function tests were normal except for decreased serum albumin and total of 2.7 and 4.7 '°"'m~·"n Throat, blood
culture was sent to the as,,v;;n," r.nr,orcwu at the Center for Disease The patient's clinical condition continued to improve. By 15 days postoperatively the creatinine had decreased to L6 mg./ d.1. and an excretory urogram did not reveal any persistent extravasation or obstruction. The patient was from the hospital on oral cephalosporin therapy. When seen at followup 23 postoperatively he of of the hands and he done well and returned to work but of D!3Ct.JSSI0N
The over-all mortality rate of toxic shock syndrome has been to be 8 per cent 1 nn,~c,~1.'l,'L'3-ov,.y 95 per cent of all cases have occurred menstruating female use tampons.2- 3 JI/fore than 900 cases of toxic shock syndrome have been ,·,.,non.,•11 to the Center for Disease Control since October 1979. Ov>ov,,o,y. the Toxic Shock ¼;,~,,wwn,n Force of the Center for Disease Control has ~h~A~rc,,, of this syndrome not associated with menstruation, which occurred in a of clinical ···-····-·..,, 8 wound infections.4 as
A from the intravenous F,V'""'""'·'-·''-' C.l:eHHU.,H.IUtmo. 1~he systolic blood pressure decreased to 60 and there vrns still no urine output 2 hours lateL Corticosteroids and and the received 5 L of fluid •Has 98.3F, blood pressure had increased 16 hours after rhea persisted as did the rash but the cyanosis Dopamine was discontinued within 24 hours after uvs-p-,t,,:;·.,';,,:-a~tion. At 9 days po,stimi3ntt1,1ely the creatinine decreased to 3.4 mg./ dl. but there was still no obvious source of infection. A diethylenetriaminepentaacetic acid renal scan demonstrated extravasation of urine from the ureterotomy site and a small retro peritoneal urinorna (see figure). The posterior aspect of the flank incision was opened and 50 ml. of purulent drainage was obtained. Culture of this material revealed 4+ coagulase positive, ,B-lactamase producing Staphylococcus aureus. A subav,-mHLaHV
Accepted for publication March 24, 1982. Read at annual meeting of Western Section, American Urological Diethylenetriaminepentaacetic acid renal scan shows extravasation Association, Coronado, California, February 21-25, 1982. from ureterotomy site. 1305
-1306
DUNN, CAPP AND FERGUSON
by staphylococcal exotoxin or toxins. The consistent finding of staphylococcal local infections in the absence of bacteremia lends further credence to this concept. 3 Criteria for the diagnosis of toxic shock syndrome include: 1) temperature >38.9C (102F), 2) erythematous macular rash, 3) desquamation during recovery phase, 4) systolic blood pressure ~90 mm. Hg for an adult, 5) involvement of at least 4 organ systems and 6) reasonable evidence of the absence of meningococcal infection, Rocky Mountain Spotted Fever, bacteremia or other known diagnostic possibility. 5 Effective management of toxic shock syndrome must include early recognition and aggressive therapy of the life-threatening manifestations of the disease. Massive fluid therapy, appropriate antibiotics and in some patients inotropic drug support are cornerstones of therapy. A penicillinase resistant penicillin or cephalosporin is essential. The urologist is alerted to the pos-
sibility of toxic shock syndrome occurring within the scope of his practice. REFERENCES 1. Ganem, D.: Toxic shock syndrome-medical staff conference, University of California, San Francisco. West. J. Med., 135: 383, 1981. 2. Davis, J.P., Chesney, P. J., Wand, P. J., LaVenture, M. and the Investigation and Laboratory Team: Toxic-shock syndrome. Epidemiologic features, recurrence, risk factors and prevention. New Engl. J. Med., 303: 1429, 1980. 3. Fisher, C. J., Jr., Horowitz, B. Z. and Nolan, S. M.: The clinical spectrum of toxic shock syndrome. West. J. Med., 135: 175, 1981. 4. Reingold, A. L., Dan, B. B., Shands, K. and Broome, C.: Toxicshock syndrome not associated with menstruation. Lancet, 1: 1, 1982. 5. Tanner, M. H., Pierce, B. J. and Hale, D. C.: Toxic shock syndrome. West. J. Med., 134: 477, 1981.
,rol. 128, Decernber Printed ir,, U.S.A.
CF
Copyiigbt © 1982 by The ·\iVillia.ms & Wilkins
STEPHEN R
CHARLES D. CAPP
AND
DAVID VV. FERGUSON
From the Urology and Medical Services, Mercy Medical Center, Redding, California
ABSTRACT
Toxic shock syndrome is a much p~,u,.,~,.~~ disease that has been '°"'""'n.",-'°',.., most often in female who use tampons. It has been linked to infection with certain strains of staphylococci. We describe the first case, of which we are aware, of this as a e,uu11uu...,a.ue,,u of urologic surgery. A man underwent an uncomplicated right mid ureterolithotomy on June 3, 1981 for a 4 X 7 mm. calcium oxalate calculus. The urine was sterile and the immediate postoperative course was unremarkable. Urine drainage was moderate until 3 days postoperatively, when it ceased and the Penrose drain was removed. At 5 days 1xistoper,at1veJ the patient was afebrile with a white blood count he was discharged from the hospital. The next experienced chills ar,d and nausea, vomiting and diarrhea. Physical examination disclosed a ill man who was delirious. Temperature was 102.GF and blood pressure was 84/ 34 mm. Hg. The rate was 120 per minute and difficult to palpate. The were and there v,as a confluent, bright red truncal rash that blanched on pressure. The sclera was injected and the tongue was dry but otherwise unremarkable. There was no pharyngitis. The chest was clear and auscultation of the heart reveaied a sinus n½"nn=," but or rubs. Abdominal examination was unflank incision had no evidence of wound infection. Neuxologic examination disclosed disturbed mentation but no lateralizing findings. The remainder of the w, n,1u~.1 examination was unremarkable. The white blood count was 17,400 with 75 3 monocytes. The 20 2 1y,.111-1uc,1..,i uc,uv,,..,v,nH was 14.9 gm. were normal except for a low serum calcium of 7.0 mg./dl. Bbod urea n,·t-rr,rre,r, was 43 and creatinine was 4.6 mg./dL Liver function tests were normal except for decreased serum albumin and total of 2.7 and 4.7 '°"'m~·"n Throat, blood
culture was sent to the as,,v;;n," r.nr,orcwu at the Center for Disease The patient's clinical condition continued to improve. By 15 days postoperatively the creatinine had decreased to L6 mg./ d.1. and an excretory urogram did not reveal any persistent extravasation or obstruction. The patient was from the hospital on oral cephalosporin therapy. When seen at followup 23 postoperatively he of of the hands and he done well and returned to work but of D!3Ct.JSSI0N
The over-all mortality rate of toxic shock syndrome has been to be 8 per cent 1 nn,~c,~1.'l,'L'3-ov,.y 95 per cent of all cases have occurred menstruating female use tampons.2- 3 JI/fore than 900 cases of toxic shock syndrome have been ,·,.,non.,•11 to the Center for Disease Control since October 1979. Ov>ov,,o,y. the Toxic Shock ¼;,~,,wwn,n Force of the Center for Disease Control has ~h~A~rc,,, of this syndrome not associated with menstruation, which occurred in a of clinical ···-····-·..,, 8 wound infections.4 as
A from the intravenous F,V'""'""'·'-·''-' C.l:eHHU.,H.IUtmo. 1~he systolic blood pressure decreased to 60 and there vrns still no urine output 2 hours lateL Corticosteroids and and the received 5 L of fluid •Has 98.3F, blood pressure had increased 16 hours after rhea persisted as did the rash but the cyanosis Dopamine was discontinued within 24 hours after uvs-p-,t,,:;·.,';,,:-a~tion. At 9 days po,stimi3ntt1,1ely the creatinine decreased to 3.4 mg./ dl. but there was still no obvious source of infection. A diethylenetriaminepentaacetic acid renal scan demonstrated extravasation of urine from the ureterotomy site and a small retro peritoneal urinorna (see figure). The posterior aspect of the flank incision was opened and 50 ml. of purulent drainage was obtained. Culture of this material revealed 4+ coagulase positive, ,B-lactamase producing Staphylococcus aureus. A subav,-mHLaHV
Accepted for publication March 24, 1982. Read at annual meeting of Western Section, American Urological Diethylenetriaminepentaacetic acid renal scan shows extravasation Association, Coronado, California, February 21-25, 1982. from ureterotomy site. 1305
-1306
DUNN, CAPP AND FERGUSON
by staphylococcal exotoxin or toxins. The consistent finding of staphylococcal local infections in the absence of bacteremia lends further credence to this concept. 3 Criteria for the diagnosis of toxic shock syndrome include: 1) temperature >38.9C (102F), 2) erythematous macular rash, 3) desquamation during recovery phase, 4) systolic blood pressure ~90 mm. Hg for an adult, 5) involvement of at least 4 organ systems and 6) reasonable evidence of the absence of meningococcal infection, Rocky Mountain Spotted Fever, bacteremia or other known diagnostic possibility. 5 Effective management of toxic shock syndrome must include early recognition and aggressive therapy of the life-threatening manifestations of the disease. Massive fluid therapy, appropriate antibiotics and in some patients inotropic drug support are cornerstones of therapy. A penicillinase resistant penicillin or cephalosporin is essential. The urologist is alerted to the pos-
sibility of toxic shock syndrome occurring within the scope of his practice. REFERENCES 1. Ganem, D.: Toxic shock syndrome-medical staff conference, University of California, San Francisco. West. J. Med., 135: 383, 1981. 2. Davis, J.P., Chesney, P. J., Wand, P. J., LaVenture, M. and the Investigation and Laboratory Team: Toxic-shock syndrome. Epidemiologic features, recurrence, risk factors and prevention. New Engl. J. Med., 303: 1429, 1980. 3. Fisher, C. J., Jr., Horowitz, B. Z. and Nolan, S. M.: The clinical spectrum of toxic shock syndrome. West. J. Med., 135: 175, 1981. 4. Reingold, A. L., Dan, B. B., Shands, K. and Broome, C.: Toxicshock syndrome not associated with menstruation. Lancet, 1: 1, 1982. 5. Tanner, M. H., Pierce, B. J. and Hale, D. C.: Toxic shock syndrome. West. J. Med., 134: 477, 1981.