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A 37-year-old man with a febrile illness. Answer

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A 37-year-old man with a febrile illness. Answer
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  1486  •  CID 2003:36 (1 June)  •  ANSWER TO PHOTO QUIZ A N S W E R T O P H O T O Q U I Z Philip A. Mackowiak, Section Editor A 37-Year-Old Man with a Febrile Illness (See pages 1474–5 for Photo Quiz)Figure 1.  Left eye at the time of admission to the Department of Medicine (4 days after the onset of an abrupt febrile illness) Diagnosis: Staphylococcal toxic shock syndrome.Abrupt febrile illness with jaundice (figure 1) followed by skin desquamation, as seen above the eyebrows and below thelower eyelid (figure 2) and especially on the palms (figure 3),is typical for staphylococcal toxic shock syndrome. Before thisillness, the patient had a pustular lesion on his groin, whichhad almost completely resolved and had dried when the symp-toms of toxic shock syndrome developed. On the fourth day of his illness, the patient was admitted to the Department of Medicine with jaundice (figure 1) and a diffuse, finely des-quamating macular rash on the limbs, torso, and face. He ap-peared to be severely ill, with a temperature of 39.3  C, a heartrate of 120 beats/min, blood pressure of 105/55 mm Hg, anda respiratory rate of 40 breaths/min. A scaled, small, pustularlesion was found on the right groin. Diffuse, fine rales wereheard over both lungs, and chest radiography revealed bilateralinterstitial infiltrates.Laboratory tests revealed a leukocyte count of 12,000 leu-kocytes/mm 3 , with 50% band forms. The platelet count andcoagulation test values were in the normal range. The patient’sblood urea nitrogen level was 30 mg/dL, and his creatininelevelwas 1.5 mg/dL. The blood pH was 7.45, the partial pressure of carbon dioxide was 28.5 mm Hg, and the partial pressure of oxygen was 61 mm Hg, with oxygen saturation of 87%. Thedirect bilirubin level was 8.6 g/dL, the aspartate aminotrans-ferase level was 130 U/L, and the alanine aminotransferaselevelwas 145 U/L. The creatine kinase level was 230 U/L. The resultsof blood cultures and serological tests for rickettsial diseases,leptospirosis, and measles were negative.Toxic shock syndrome was diagnosed at admission to theDepartment of Medicine on the basis of the established criteria[1]. The patient was treated with intravenous cloxacillin (2 gq.i.d.) and clindamycin (600 mg t.i.d.) for 10 days. Fever re-solved after 48 h, but desquamation extended (figure 2) andinvolved the palms (figure 3) and soles. Subconjunctival hem-orrhages (figure 2) (rather than hemorrhagic conjunctivitis be-cause the limbus and pinguecula were spared) are likely theresult of vomiting and a later cough due to acute respiratory distress syndrome. All findings resolved within 2 weeks afterhospital admission.The combination of jaundice with a febrile illness has a con-siderable differential diagnosis. However, the presence of rash,   b  y g u e  s  t   onA u g u s  t  1  0  ,2  0 1  6 h  t   t   p :  /   /   c i   d  . oxf   or  d  j   o ur n a l   s  . or  g /  D o wnl   o a  d  e  d f  r  om   ANSWER TO PHOTO QUIZ  •  CID 2003:36 (1 June)  •  1487 Figure 2.  Left eye 8 days after the onset of an abrupt febrile illness Figure 3.  Skin desquamation on the palm 10 days after the onset of an abrupt febrile illness multiple organ system involvement, and, in particular, des-quamation of palms and soles 7–14 days after the onset of symptoms, while the patient is recovering from sepsis, is quitespecific for staphylococcal toxic shock syndrome [1]. Non-menstrual toxic shock syndrome, a life-threatening illness, cancomplicate an innocuous or inapparent infection [2], as thiscase demonstrates. Oren Zimhony, 1 Svetlana Chebatco, 2 and Ami Schattner 2 1 Infectious Diseases Unit and  2 Internal Medicine Department A, Kaplan MedicalCenter and Hebrew University, Hadassah Medical School, Jerusalem, Israel References 1. Chesney PJ, Davis JP, Purdy WK, Wand PJ, Chesney RW. Clinical man-ifestations of toxic shock syndrome. JAMA  1981 ;246:741–8.2. Reingold AL, Hargrett NT, Dan BB, Shands KN, Strickland BY, BroomeCV. Nonmenstrual toxic shock syndrome. Ann Intern Med  1982 ;96:871–4. Reprints or correspondence: Dr. Oren Zimhony, Infectious Diseases Unit, Dept. of Medicine,Kaplan Medical Center, PO Box 1, Rehovot, Israel, 76100 (oren_z@clalit.org.il). Clinical Infectious Diseases 2003;36:1486–7   2003 by the Infectious Diseases Society of America. All rights reserved.1058-4838/2003/3611-0019$15.00   b  y g u e  s  t   onA u g u s  t  1  0  ,2  0 1  6 h  t   t   p :  /   /   c i   d  . oxf   or  d  j   o ur n a l   s  . or  g /  D o wnl   o a  d  e  d f  r  om 
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