Epidemiologic Notes and Reports Toxic Shock Syndrome Associated with Influenza -- Minnesota

During February 1986, the Minnesota Department of Health (MDH) identified two cases of toxic shock syndrome (TSS) following influenza infection. Both patients were male, 15 and 16 years of age. Both met the CDC case definition as confirmed TSS cases. Both had laboratory confirmation of influenza B infection. One patient died. In each, an infiltrate was noted on chest x-ray; Staphylococcus aureus was isolated from respiratory secretions; one strain produced TSS toxin-1, and the other was positive for staphylococcal enterotoxin B.

After report of the first case, to identify other potential cases of TSS following influenza-like illness, the MDH conducted initial surveillance by contacting major pediatric hospitals and trauma centers in the state and infectious disease specialists in the Twin Cities (Minneapolis-St. Paul) metropolitan area. The MDH surveillance case definition included the presence of an antecedent respiratory illness, followed by hypotension (systolic blood pressure 90 mm/Hg or lower), fever (38.8 C (102 F)), and negative blood cultures. This led to identification of the second confirmed TSS case. Four other patients with probable TSS following influenza-like illnesses were identified. All four of the patients were hospitalized with severe shock, fever, and multisystem involvement. None had observed erythoderma, but three of the four desquamated. The fourth patient died 3 days after admission. These cases are currently under investigation. The MDH is maintaining surveillance to identify additional cases. Reported by P Bitterman, MD, University of Minnesota Hospitals, G Peterson, MD, Hennepin County Medical Examiner's Office, P Schlievert, PhD, University of Minnesota, G Lehman, MD, C Schrock, MD, North Memorial Medical Center, Robbinsdale, MJ Connolly, MD, St. Joseph's Hospital, J Flink, MD, United Hospitals, G Kravitz, MD, St. Joseph's Hospital and St. John's Hospital, S Leonard, MD, Children's Hospital, St. Paul, M Osterholm, PhD, State Epidemiologist, Minnesota Dept of Health; Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note:National surveillance of influenza indicates this influenza season has a high level of activity, which increases the chances of detecting rare sequelae of influenza infections. The cases described above and 14 additional cases reported to CDC of profound hypotension in previously healthy persons following influenza-like illness warrant investigation to clarify the pathogenesis of these unusual cases and to confirm the relationship to influenza infection.

In the patients reported to CDC, the etiology of the rapidly developing, sometimes refractory, hypotension is under investigation. Blood cultures have been negative, and in most, severe pneumonia with consolidation has not been a prominent feature. The differential diagnosis of sudden shock in this clinical setting includes myocarditis, TSS, and septic shock. The differentiation of these illnesses can be difficult, often requiring hemodynamic monitoring, serologic testing, and cultures from appropriate clinical specimens. Myocarditis has been described as a complication of influenza infections (1,2), although documentation can be difficult. The TSS diagnosis is based on a clinical case definition (3), but the rash is not always apparent and may be overlooked.

Staphylococcus aureus pneumonia following influenza has been well documented (4,5). The occurrence of a toxic-shock-like syndrome after antecedent influenza is consistent with this pattern (6), as TSS is caused by toxin-producing S. aureus strains.

Physicians who have seen patients with severe shock following influenza-like illness in previously healthy individuals are encouraged to report such cases through their local/state health departments to the Meningitis and Special Pathogens Branch, Division of Bacterial Diseases, Center for Infectious Diseases, CDC, Atlanta, Georgia 30333; telephone (404) 329-3687. Consultation is available regarding the collection of clinical information and laboratory specimens that may help define the etiology of these illnesses. Reported by Meningitis and Special Pathogens Br, Div of Bacterial Diseases, Epidemiology Office, Influenza Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

References

1. Finland M, Parker F, Barnes MW, Jolitte LS. Acute myocarditis in influenza A infections. Two cases of non-bacterial myocarditis with isolation of virus from the lungs. Am J Med Sci 1945;209:455-68.

2. Adams CW. Postviral myopericarditis associated with influenza virus: Report of eight cases. Am J Cardiol 1959;4:56-67.

3. Reingold AL, Hargrett NT, Shands KN, et al. Toxic shock syndrome surveillance in the United States, 1980 to 1981. Ann Intern Med 1982;96:875-80.

4. Martin LM, Kunin CM, Gottlieb LS, et al. Asian influenza A in Boston, 1957-1958 II. Severe staphylococcal pneumonia complicating influenza. Arch Intern Med 1959;103:532-42.

5. Schwarzmann SW, Adler JL, Sullivan RJ Jr, Marine WM. Bacterial pneumonia during the Hong Kong influenza epidemic of 1968-1969. Experience in a city-county hospital. Arch Intern Med 1971;127:1037-41.

6. Langmuir AD, Worthen TD, Solomon J, Ray CG, Petersen E. The Thucydides syndrome. N Engl J Med 1985;313:1027-30.

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