This patient is suffering from toxic shock syndrome (TSS). The management of toxic shock syndrome is primarily supportive with aggressive IV fluid rehydration and antibiotics.
Toxic shock syndrome most commonly occurs in women using tampons within 5 days after the onset of their menstrual period. The presentation of TSS includes fever, nausea/vomiting, diarrhea, conjunctivitis, and diffuse "sunburn-like" rash. Desquamation of the palms and soles typically occurs during recovery, 1-2 weeks after the acute phase of the illness. The cornerstone of treatment is IV fluid rehydration and antibiotics. There are numerous complications that may develop as a result of TSS and require attention, including acute respiratory distress syndrome requiring mechanical ventilation, renal failure requiring dialysis, and disseminated intravascular coagulation/hemorrhage.
Bryner discusses the wide variety of etiologies of toxic shock syndrome beyond the association with tampons/menstruation, noting that nonmenstrual toxic shock syndrome is often a diagnosis that is initially overlooked. Associated clinical conditions can include barrier contraceptive use, surgical wound infection, burn wounds, cuts or other skin lesions, or arthritis. Approximately 50% of TSS cases are nonmenstrual, with 25% of these occurring in men.
Low discusses the pathogenesis of and limited treatment options for toxic shock syndrome. TSS is due to antigen-mediated cytokine storm and concomitant neutrophil activation resulting in the release of inflammatory mediators that ultimately cause respiratory failure, vascular leakage, and shock. Streptococcal TSS carries a mortality of around 50%; however, studies are ongoing to investigate a potential role for IVIG in the treatment of this disease.
Figure A is a "red, strawberry" tongue, a relatively common manifestation of toxic shock syndrome. Figure B is an image of the diffuse macular erythematous rash characteristic of toxic shock syndrome. Illustration A is a timeline of the presenting characteristics of toxic shock syndrome. Illustration B is a depiction of the pathogenesis of TSS.
Answer 1: Antibiotics are recommended in the treatment of TSS; however, empiric treatment involving penicillin G requires combination with an additional beta-lactamase resistant antibiotic until culture results are returned. Additionally, clindamycin has been demonstrated to be a superior agent for Streptococcal TSS. For Staphylococcal TSS, nafcillin, oxacillin, a 1st-generation cephalosporin, or vancomycin are typically recommended.
Answer 3: High-dose corticosteroid therapy has not been shown to be beneficial for TSS patients; stress-dose therapy may be useful in patients with refractory shock. Treatment should always start with IV hydration support and source control (antibiotics, I&D, etc).
Answer 4: Doxycycline is the appropriate treatment for Rocky Mountain Spotted Fever, a disease in the differential diagnosis of TSS. RMSF differs from TSS in that RMSF involves headache and a petechial (as opposed to diffusely erythematous) rash that starts on the palms and soles. This patient's presentation is much more suggestive of TSS.
Answer 5: An I&D is appropriate for TSS cases due to underlying infection such as necrotizing fasciitis, which does not fit this patient's presentation.