Toxic-Shock Syndrome in a Patient Using a Continuous
Subcutaneous Insulin Infusion Pump--Idaho
In May 1983, a 12-year-old, pre-menarchal, diabetic girl from
Idaho developed a Staphylococcus aureus abscess at a needle
insertion
site and toxic-shock syndrome (TSS).
The patient had onset of Type I (insulin-dependent) diabetes
mellitus at age 9 but had no evidence of the chronic complications
of
diabetes, such as retinopathy, neuropathy, nephropathy, or
atherosclerotic cardiovascular disease. She began continuous
subcutaneous insulin infusion (CSII) pump therapy at age 11 because
of
poor control of her diabetes mellitus. She was instructed to swab
the
infusion site with povidone-iodine solution before inserting the
subcutaneous needle, to apply povidone-iodine ointment and a
plastic
dressing to the insertion site, and to change the site every 3
days.
However, frequently she did not change the site more than every 10
days. For 1-2 weeks before she was admitted to the hospital, she
noted intermittent purulent drainage from several subcutaneous
needle
insertion sites.
The day before admission, the patient had onset of generalized
muscle pain and puffiness of the face and hands. The day of
admission, she presented with diabetic ketoacidosis, severe
abdominal
pain, diarrhea, and fever. Because of abdominal tenderness, an
exploratory laparotomy was performed; no abnormality was found.
Before and after surgery, her systolic blood pressure was as low as
70
mm Hg, and her temperature was 39.4 C (103 F). Four hours after
surgery, she had marked diffuse erythroderma and conjunctival
suffusion. She was irritable and lethargic but coherent. Vaginal
examination was normal. Two subcutaneous needle-insertion sites
had
1-2 cm areas of induration with no purulent discharge or erythema.
Laboratory tests revealed a white blood cell count of 21,000 and
platelet count of 367,000. Hemoglobin declined from an admission
value of 15.8 g/dl to 10.6 g/dl. Blood urea nitrogen, serum
creatinine, and liver function tests were normal. Prothrombin and
partial thromboplastin times were normal. Antistreptolysin-O titer
was negative. Urinalysis showed 15-18 leukocytes/hpf and was
culture-negative. Chest x-ray was normal. A throat culture was
positive for S. aureus and negative for Group A beta-hemolytic
streptococci. Blood, vaginal, and stool cultures were negative.
The patient was treated with intravenous doxycycline and
cefamandole and showed significant clinical improvement by the
second
day of therapy with resolution of her hypotension, diarrhea,
erythroderma, and fever. After 7 days of therapy, she was
discharged
from the hospital. Two days later, there was a 5-10 cc purulent
drainage from one of her CSII sites. Gram stain showed white cells
and gram-positive cocci, and culture yielded S. aureus. Seven days
after onset of illness, she began to have desquamation of the skin
from the palms of her hands. She had an uneventful recovery.
Reported by MH Tanner, MD, D Hale, MD, J Liljenquist, MD, Riverview
Hospital, Idaho Falls; CD Brokopp, DrPH, State Epidemiologist,
Idaho
Dept of Health and Welfare. M Haffner, MD, Food and Drug
Administration. Technology and Operational Research Br, Div of
Diabetes Control, Center for Prevention Svcs; Hospital Infections
Program; Respiratory and Special Pathogens Br, Div of Bacterial
Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: CSII pumps are external, battery-powered devices
that
administer insulin through subcutaneous needles. In an effort to
improve glycemic control among patients with diabetes mellitus, use
of
these pumps has increased rapidly in recent years. Infection at
the
infusion site is among the most frequently encountered
complications
of CSII pump therapy (1,2). The present case, as well as a
previously
reported death attributed to endocarditis secondary to an abscess
at a
CSII needle insertion site (3), show that serious disease can
result.
This patient met CDC's revised case definition of TSS (4). Her
CSII needle insertion site abscesses were not cultured until after
her
discharge from the hospital, but they were the most likely sites of
S.
aureus infection. It was unlikely that her surgical wound was the
source, since most of the TSS symptoms were present before surgery.
S. aureus cultured from her throat may have been the source of TSS,
but the abscesses were a much more likely source. Twenty-nine of
130
non-menstrual cases of TSS have been previously associated with
non-surgical cutaneous or subcutaneous lesions (5).
No specific procedural guidelines--including optimum frequency
of
needle and administration changes--are available to minimize the
risk
of subcutaneous infections associated with CSII pumps. In the
absence
of such information, physicians are encouraged to educate patients
using these devices to the following recommendations (modified from
CDC's Guideline for Prevention of Intravascular Infections (6)).
Patients should wash their hands before inserting a
subcutaneous
needle.
The infusion site should be scrubbed with an antiseptic before
needle insertion. Tincture of iodine (1%-2%), chlorhexidine,
iodophor, or 70% alcohol can be used. The antiseptic should be
applied liberally and allowed to remain in contact for at least
30
seconds before needle insertion. Aqueous benzalkonium-like
compounds should not be used to scrub the catheter site.
The needle should be secured to stabilize it at the insertion
site.
A sterile dressing should be applied to cover the insertion
site.
The dressing, not tape, should cover the wound, unless the tape
is
sterile.
The infusion site and administration set should be changed and
a
new needle inserted at least every 48-72 hours.
Patients with CSII devices should be instructed to evaluate the
insertion site at least daily for evidence of needle-related
infections. This evaluation should include gentle palpation of
the insertion site through the intact dressing. If the patient
has an unexplained fever or pain or tenderness at the insertion
site, the dressing should be removed and the insertion site
inspected. If a draining abscess or cellulitis is noted, the
administration set and needle should be changed immediately;
the
patient should seek appropriate medical attention, and
appropriate
cultures should be obtained.
References
Pietri A, Raskin P. Cutaneous complications of chronic
continuous
subcutaneous insulin infusion therapy. Diabetes Care
1981;4:624-6.
Mecklenburg R, Sannar C, Becker N, et al. Frequency of
complications associated with insulin pump therapy: report of
experience with 198 patients. (abstract) Diabetes 1983;32(Suppl
1):35A.
CDC. Update: Deaths among patients using continuous
subcutaneous
insulin infusion pumps--United States. MMWR 1982;31:625-6.
Reingold AL, Hargrett NT, Shands KN, et al. Toxic shock
syndrome
surveillance in the United States, 1980 to 1981. Ann Intern
Med
1982;96(6 Pt 2):875-80.
Reingold AL, Hargrett NT, Dan BB, Shands KN, Strickland BY,
Broome
CV. Nonmenstrual toxic shock syndrome: a review of 130 cases.
Ann Intern Med 1982;92(6 Pt 2):871-4.
Simmons BP, Hooton TM, Wong ES, Allen JR. Guidelines for
prevention of intravascular infections. Infect Control
1982;3:61-72.
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