(1420) Untreated Sinusitis Leading to Life-Threatening Toxic Shock Syndrome

Introduction: TSS is an acute systemic illness that resembles septic shock and is caused by bacterial infections by organism-producing superantigens like Staphylococcus aureus and group A Streptococcus. Acute sinusitis is a common inflammation of the sinuses with several expected complications. However, TSS secondary to acute sinusitis is not common.

Methods: 67y F with a history of COPD and HTN was brought to the hospital for generalized weakness and found to be tachycardic, tachypneic, febrile, hypotensive and unresponsive in the hospital and required intubation. According to the husband, she had been complaining of sinus congestion and left ear pus drainage but had not sought medical help. CXR showed bilateral lung congestion, labs: leukocytosis, CRP 27.9, AKI and respiratory acidosis in ABG. Gram stain grew rare gram-positive cocci in pairs, and sputum culture grew Strept pyogenes. Her blood culture also grew Strept pyogenes. A couple of days after receiving antibiotics, the patient developed a rash and then vesicles with fluid. TSS was one of the differentials, a search was conducted for a tampon, nasal packing, or foreign body, and any new medications started recently that could cause a skin rash. The patient received clindamycin and IVIG to cover the toxin, and antibiotics were administered to cover the bacteria.

Results: Superantigens bypass the normal pathway for the activation of T cells, generating the massive secretion of pro-inflammatory cytokines and producing a capillary leak and hypotension, Staphylococci and streptococci are the most common organisms. Superantigens have the ability to bind to MHC II molecules outside of the antigen groove, triggering the activation of both the antigen-presenting cell and T lymphocyte bypassing conventional mechanisms of MHC-limited antigen cell activation. Since immune cell activation is not restricted to cells expressing and recognizing a single antigen, but rather polyclonal, cell activation is massive and explains systemic pro-inflammatory activity, arterial hypotension, and end-organ dysfunction.

Conclusions: We highlight the importance of seeking medical attention for symptoms of sinusitis. Timely treatment can prevent the development of complications such as TSS. Clinicians should be aware of the potential for TSS in patients with acute sinusitis.