A 15 year old girl was admitted to the Paediatric ward. The clinical information given was 'toxic shock syndrome?'. The serum results were as follows:
Sodium: 129 mmol/L (134 - 145)
Potassium: 4.0 mmol/L (3.6 - 5.3)
Urea: 14.2 mmol/L (2.8 - 7.0)
Creatinine: 124 µmol/L (62 - 133)
Albumin: 26 g/L (35 - 49)
Globulin: 31 g/L (17 - 35)
Total bilirubin: 34 µmol/L (3 - 22)
Alkaline phosphatase: 66 IU/L (38 - 126 adult range)
ALT: 41 IU/L (7- 56)
GammaGT: 84 IU/L (12 - 58)
There were 34 participants in this case. There was no clear consensus in this case. The assessors also had differing views on several comments (these are marked with an asterisk*).
8 participants would contact the Doctor to discuss the case and obtain a better history. [1.5]
8 would not comment on these results. [0.3]
7 would comment that these results were consistent with toxic shock syndrome or sepsis. [1]
4 participants would comment that the creatinine and/or urea is high for a 15y old. [0]*
4 would query the possiblity of a recent paracetamol overdose or would add sal/paracetamol before reporting. [-0.5]*
4 would comment low albumin- ?proteinuria or liver problem. [0.3]*
3 would suggest that Addison's should be excluded. [0.8]
3 would query rhabdomyolysis and would add CK. [1]
3 would query drug/alcohol problem. [0]*
3 would comment low sodium with uraemia. [-0.5]
3 would query hypovalaemia/dehydrated? [0.8]
2 participants would query nephrotic syndrome. [0.3]
2 would liase with the microbiologists over blood cultures.[0]
2 participants would query glomerulonephritits. [-0.3]*
2 would query if any diarrhoea or vomiting- any exposure to E.Coli 0157? [-0.3]*
1 participant would comment low albumin- ?cause. [0]
1 would comment that raised urea may suggest pre-renal failure. [0.3]
1 would comment- would not expect a 1- 2 day toxic shock to give this picture. [-0.3]
1 participant would comment low alk phos with raised gammaGT- ?nutritional deficiency or low phosphate? [-1]
1 would query ectasy induced dehydration? [-0.5]*
1 would comment- raised bilirubin- exclude haemolysis or H-U syndrome? [0.8]
1 would suggest careful monitoring of U & Es. [-1]
1 would query Crohns? Any history of anoxeria nervosa? [-0.8]
5 participants would suggest measuring urine sodium [1]
4 participants would each add;
CRP [1]
glucose [0.5]
calcium [0.3]
4 would suggest urine protein. [0.8]
3 would suggest repeat with calcium/phosphate/magnesium.[0]
2 would each suggest;
24h urine protein [1]
urine drug screen [0.5]*
urine osmolality [0.5]
serum osmolality [0.3]
repeat with LFTs and bicarbonate [0.3]
1 would suggest checking for haemoglobinuria. [0.5]
1 would add cortisol. [0.8]
This was a difficult case to comment on as we do not have much experience with toxic shock syndrome. I could not contact the Doctor but the nursing staff on the ward confirmed that the patient was generally very poorly. She had initially presented at Accident and Emergency with pyrexia, rigours and a rash. Her clavicle and humerus had been broken 10 days earlier in a traffic accident. They suspected toxic shock or sepsis. We added CRP to the sample which was raised at 40mg/L (reference range <5).
Her condition deteriorated and she was transferred to Intensive Care. She did not have a retained tampon and her blood cultures were negative. The pins inserted into her fractured humerus were removed as a possible site of infection but they also cultured negative. The working diagnosis was a secondary infection following the traffic accident and that toxic shock syndrome was secondary to this. She responded well to antibiotics and supportive treatment. Her renal function improved and LFTs returned to normal. She was discharged from hospital a week later.
I commented 'dehydrated? Low albumin due to acute phase response?'
Best wishes
Jacqui
Gordon
