Extreme lymphocytopenia associated with toxic shock syndrome

Galus MA, Stern J (Medical University of South Carolina, Charleston and Pennsylvania Hospital, Philadelphia, USA). Extreme lymphocytopenia associated with toxic shock syndrome (Case Report). J Intern Med 1998; 244: 351–354. We report an unusual case of extreme lymphocytopenia associated with staphylococcal toxic shock syndrome. A young, sexually promiscuous man presented with high fevers, productive cough, nausea with occasional vomiting, mild headache and right midthoracic and shoulder pain. His initial lymphocyte count was 72. Such a presentation in an inner city hospital, where about 15% of admissions are AIDS-related, put the diagnosis of AIDS high on the differential list. However, the CD4:CD8 ratio was 1.7, which was inconsistent with AIDS diagnosis. Further work-up led to diagnosis of toxic shock syndrome due to staphylococcal epidural abscess. The patient's lymphocyte count normalized with antibiotic treatment. A 30-year-old man presented because of high fevers, chills, productive cough, nausea with occasional vomiting and mild headache for 3 days. He also complained of right midthoracic back pain and right shoulder pain which started after he lifted a heavy object a few days earlier. He had no diarrhoea. His primary physician treated him with amoxicillin, darvocet and flexeril without significant improvement. Past medical history was significant for three episodes of meningitis in childhood. He denied intravenous drug use, but admitted to having sex with many partners. He looked ill, his temperature was 40 °C, blood pressure was 98/50 mmHg, with a pulse of 160 min−1 and respiratory rate of 24 min−1. After intravenous fluids, his blood pressure rose to 120/70 mm Hg with a pulse of 130 min−1. There was a faint diffuse macular erythematous rash on the trunk and extremities. There was no nuchal rigidity. Cardiac examination revealed no gallops or murmurs. There were crackles at the right lung base. Examination of the abdomen was benign. There was tenderness to palpation of the right paraspinal muscles at midthoracic level, but no pain along the extent of the cervical and thoracic spinous processes. Neurological examination was non-focal. The results of blood tests are listed in Table 1. Chest X-ray showed increased interstitial markings. A sputum Gram stain showed Gram-positive cocci in clusters, and sputum culture grew normal flora. Lumbar puncture revealed 43 leucocytes mm−3 with 84% of polymorphonuclear neutrophils and 16% of monocytes, glucose 64 mg dL−1, protein 59 mg dL−1 and no organisms were seen. No India ink examination was performed. The patient was started on broad antibiotic coverage. Chest X-ray repeated after intravenous fluid administration revealed bibasilar infiltrates and generalized increase in interstitial markings, suggesting opportunistic infection. Increased alveolar–arterial gradient persisted. Cerebrospinal fluid, blood and throat cultures showed no growth of bacteria after 24 h. Liver function tests showed slightly elevated transaminases, total bilirubin and alkaline phosphatase. Empiric therapy for Pneumocystis carinii pneumonia was begun. The patient underwent bronchoscopy which revealed acute inflammation but no Pneumocystis carinii or acid-fasting bacilli. Rapid respiratory panel was also negative after 24 h. HIV test and RPR were non-reactive. CD4 count was 43, and CD8 25 with a ratio of 1.7. Therapy for Pneumocystis carinii was discontinued, and broad antibiotic coverage was continued. On the fourth day of hospitalization, the patient started to feel better, but was still febrile. Although unlikely, doxycycline was added to cover Rocky Mountain spotted fever, leptospirosis and ehrlichiosis. A skin biopsy revealed slight chronic inflammation and telangiectasia consistent with a viral exanthem. An abdominal ultrasound was normal. Hepatitis panel was negative and rubella titres were negative. There was a low level of rubeola IgG antibodies; mono-spot and rapid respiratory panel were negative for viral infections. By the sixth day of hospitalization, clinically the patient improved further. He was feeling much better, had more energy, no shorthness of breath, only a low-grade temperature, and his rash had cleared. He still complained of some right midthoracic pain and right shoulder pain. He developed desquamation of skin of the face and palms, which he insisted was an old recurrent problem secondary to an occupational exposure preceding this illness. Ehrlichia antibodies were negative, cold agglutinin titre was low, parvovirus IgG antibodies were positive with a negative IgM; R. typhi < 1:64, R. rickettsii < 1:64. His white cell count remained persistently elevated at 14 000 mm−3, but left shift with bandaemia resolved. The plan was to complete a 10-day antibiotic course and discharge the patient home. Despite clinical improvement, his alkaline phosphatase rose to 850 units L−1, total bilirubin of 2.3 mg dL−1, with normal transaminases. A repeat abdominal ultrasound was unremarkable. Following antecubital placement of heplock on the 10th day in hospital, the patient started to complain of numbness and weakness of the right hand. Neurological examination revealed weakness in the right upper extremity in a multiple nerve distribution. The neurologist suggested that the weakness might be factitious; however, he recommended an MRI of the cervical spine. The MRI revealed an epidural abscess at the level of C7–T1 and T1 osteomyelitis. The patient underwent emergent laminectomy and drainage of 10 mL of pus. Cultures grew methicillin-susceptible Staphylococcus aureus. The patient was discharged to home in a stable condition to complete a prolonged course of intravenous antibiotic therapy as an outpatient. Weakness in his hand improved after a neurosurgical procedure. Just before discharge the patient gave additional history of recent contact dermatitis of the palms for which he was receiving weekly intramuscular steroid injections.