If your first thought upon reading the subject was "tampons," then congrats, you're normal. (If you don't know what that is, then that's normal too.) If your first thought was something other than tampons or nothing, then you're a freak of nature. (sorry. I hate to be mean, but really...what else is there besides "tampons"? Freak.)
We learned about it at some point second year of med school and they didn't teach us anything you can't find on the side of a tampon box. It's not particularly common, even among dedicated tampon wearers, but it does happen, in which case the treatment is removal of the tampon. Once you get that thing out, TSS usually clears up pretty quickly. Allegedly there are other ways of catching it, but as far as me and the rest of the world can tell, that's the only important way. Also, I remember Dr. McYummy telling me that I didn't need to know anything about it since I would never see anyone with it, now that the particular brand of tampon that was responsible for causing the outbreak was recalled.
Anyway, the other night when I was on call we got consulted in the ER for a 15 year old boy who had had metal pins stuck in his arm for a humerus fracture and was now presenting with an infection. The pin sites looked fine but the kid looked pretty sick. I asked the ER attending if we could consult pediatrics to admit the kid, he agreed, the kid got admitted that night. It wound up being the right decision because something happened that night and the kid crashed. Between when I saw him on Friday evening and 6AM Sunday, the kid wound up intubated, ventilated, sedated, and with a blood pressure so low they had to start him on multiple pressors.
He was diagnosed with toxic shock syndrome, source of infection unknown.
Dr. Sweaty: They now think he has toxic shock syndrome
Me: Has he been using tampons?
***
Me: They now think [your pediatric patient with the pins] has toxic shock syndrome
Dr. Orthoking Jr.: Where is he hiding a tampon? It comes from tampons, right? I think that's what we learned in med school.
Me: I think that's the only thing we learned about it in med school.
Dr. Orthoking Jr.: It's nice to know that med school hasn't changed.
***
Dr. Orthoking Jr.: That patient who we put the pins in now has toxic shock syndrome.
Scrub Nurse: Why is he using tampons?
***
Me: Hey mom, what's the first thing you think of when you hear "toxic shock syndrome"?
Mom: TAMPONS
We took out the pins, but they looked fine and they have yet to grow anything in the microbio lab. Anyway, I'm no doctor or anything, but I'm starting to wonder if it's not completely impossible that the kid actually does have a tampon inside himself. Assuming that Chuck Palahniuk short story did not lie to me, 15 year old boys like to do...uh...disgusting things to...uh...self stimulate. So I don't think it's completely inconceivable that he could have, well, I'm not going to spell it out here. But 15 year old boys are disgusting human beings and I don't think it's out of the realm of the possible that he does, in fact, have a tampon lodged inside him and it's causing all these problems.
I really think someone should give the kid a good rectal exam, but I'm not sure how to suggest it. And i'm not exactly about to sneak into his room and do it myself. Also, I didn't really want to dwell on what the kid did or didn't have lodged in his anus. (hey, there's a reason I'm in ortho and part of it involves staying the hell away from that thing) And it's possible that the kid has some foreign body that's not disgusting that's causing this problem, but we already removed the pins. What else is there?
I guess I'll never find out.
Know of two cases; one caused by contraceptive sponge not removed, she almost died, weeks in ICU. The other was caused by mechanic boyfriend who didn't wash hands after working in solvents all day and then getting busy with girlfriend later. (YUK!)
ReplyDelete"But 15 year old boys are disgusting human beings..."
ReplyDeleteNice compassion there, doc. A 15 year old boy nearly dies. And you don't want to give him a rectal exam because you think it's too gross for you to do? Or too embarrassing to suggest? I didn't realise doctoring really was such a noble profession.
I had postpartum TSS. We will never know if it was the stitches from a second degree tear or just unlucky in postpartum period. The culture never grew, but toxins werein the blood and I was very ill. I'm thankful for our great attendings that I came through it. I will forever remember the resident asking repeatedly about Tampons and if I'd been in the sun that day. I had a severe tear and just had a baby - no way I'd put a tampon on those stitches and I was not in the sun! I've heard so many tragic stories from others who had loved ones with TSS. I'm thankful I arrived at the hospital quickly and was treated with antibiotics and fluids - it was still a long hospitalization, but I made a full recovery.
ReplyDeleteYou know it's a "thing" to put alcohol-soaked tampons up your anus to get drunk, right (mostly among kids right around the age of this, one, I'm assuming)?
ReplyDeleteMy husband was in ER recently for nosebleed for more than 24 hours (we were flying home internationally). He had pushed a tissue way up there. The ENT said that that could be a source of TSS if it went undetected. Just sayin'...
ReplyDeleteWe had a patient with TSS from an unknown source. She died. Turns out clindamycin inhibits ribosomes and is useful in reducing the amount of toxin the bacteria produce. But I guess knowing this makes me a freak.
ReplyDeleteJim Henson died of streptococcal TSS. And I know of another guy who had it and nearly died. No one knows how he got the underlying bacterial infection, but he's not the type to stuff tampons up his butt. So perhaps it is uncommon, especially in men, but entirely unheard of.
ReplyDeleteWhy is it that everytime I read the comments on this blog there are haters trying to second guess Fizzy. I for one do not come to this blog or any blog for medical advice. i come here because I enjoy reading fizzy's thoughts. So please if you do not like her opinion go read another blog, there are many to choose from.
ReplyDeleteI think anon2 is valid. The thing is he might be new here and doesn't know how sarcastic she is.
DeleteFor one thing, it's not Fizzy's post. For another, it is a totally bitchy and obnoxious post. And here's a suggestion for you: don't read the comments if you don't like them. Or read another blog. There are many to choose from.
DeleteThe clindamycin definitely does inhibit the toxins!! I could tell when the dose was due and as a pharmacist it makes no sense but when they initially discharged me on oral clindamycin, I was back within 24 hours in misery and they switched back to IV and I felt better, but I really began recover when older ID attending came on service and increased the vanco dose. I loved the clindamycin and now I don't question higher clindamycin doses the way I did as a young pharmacist. I'd take stomach upset any day over the horrible feeling all those toxins produce!
ReplyDeleteAnonymousSeptember 9, 2014 at 6:31 AM
Interesting, because classic teaching is that oral clindamycin has better bioavailability than IV. Most of the time in peds for abscesses, we just give IV to try and justify the admission (more for observation really).
DeleteI've only seen once case of TSS - in a little kid with the suspected source being an infected "bug bite". Apparently only half of TSS is related to tampon use. I know this b/c when the resident presented the case she said something like "this is an unusual case because..." and the attending went off for like 10 minutes on how perception of risk (TSS is only for women of childbearing age, HIV is only for gay men and drug users, ets) can make you miss diagnoses and kill people.
ReplyDeleteMedscape has more on TSS. http://emedicine.medscape.com/article/169177-overview#showall
No one has to sell me on Dr. Fizzy. She went out of her way, as senior resident,
ReplyDeleteto make her interns' lives more tolerable. She was in a position of power and,
rather than abuse that power, she chose to bake them cookies. Yes, she's
imperfect but aren't we all.
Thanks to those of you who defended me. Actually, I didn't write this post. It was written by Dr. orthochick. But I would defend her as vehemently as I would defend myself. Probably more.
ReplyDeleteFor the record though, I never had interns and I'm pretty sure I didn't bake them cookies, but it's a nice thought :-)
I remember my mother baking cookies and eating the dough. It used to make me sick.
ReplyDeleteBoy, I sure miss those days.
The clindamycin positively will inhibit the toxins!! I may tell once the dose was due and as a druggist it makes no sense however once they at the start discharged ME on oral clindamycin
ReplyDeleteOK, really? This is the reason why people make fun of Ortho.
ReplyDeleteTSS is basically the body's response to the toxins released during an infection (in response to a super antigen). It is seen with tampons, but really, any infection with S.aureus or Strep pyogenes can cause TSS. The criteria for TSS are pretty much the same as the APACHE score (indicating multi organ failure), except that there is also desquamation of the skin. I sub specialized in Internal Medicine (NOT ID), have never seen TSS before, and I know that there are many more causes to TSS than tampons. I can't believe that even after knowing that it's an unusual case (but, essentially, it's an INFECTION), you think that this poor 15 year old shoved a tampon up his butt, because clearly that's the ONLY cause of TSS. And you didn't even check! If you had, and had found a tampon, that would be one thing. But for you to post this, clearly without having done any reading, is just wrong. I was actually fine with this post where everyone thought that this kid had had it from a tampon until your paragraph where you actually wonder if he shoved a tampon up his butt. So wrong.
And while it has been nearly 2 decades since I did medical school, I try to read about my cases if there's an unusual presentation rather than just going off of what I remember.