Scientific letter
Molecular characterization of Staphylococcus aureus causing menstrual toxic shock syndrome in a young woman
Caracterización molecular de Staphylococccus aureus, agente causal del síndrome del shock tóxico menstrual en una mujer joven
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The most characteristic symptoms are fever, rash, hypotension, desquamation and the involvement of multiple organ systems.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Menstrual TSS (mTSS) is defined when it appears from the beginning of the menstruation and up to four days after.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> mTSS incidence has been reported to be 0.69 in 100,000 menstruating women per year and has been associated with high morbidity and mortality rate in previously healthy women.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">mTSS is caused by superantigen-producing <span class="elsevierStyleItalic">Staphylococcus aureus</span> (SA) or group A <span class="elsevierStyleItalic">Streptococcus,</span> and has been associated with the use of different vaginal devices as tampons or menstrual cups.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> SA superantigen, named toxic shock syndrome toxin-1 (TSST-1), is encoded by <span class="elsevierStyleItalic">tst</span> gene and is responsible for mTSS by its ability to trigger excessive and non-conventional T-cell activation with consequent downstream activation of other cell types, and cytokine/chemokine release.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We report a case of a 15-year-old menstruating woman who was hospitalized in the Intensive Care Unit (ICU) with suspicion of septic shock in the context of purulent vaginal discharge. The presented symptoms were malaise, fever (38.9<span class="elsevierStyleHsp" style=""></span>°C), sore throat, diarrhoea, rash and painful genital ulcers of 3 days of evolution. Physical examination was remarkable for a low blood pressure (80/50<span class="elsevierStyleHsp" style=""></span>mmHg), diffuse erythematous macular rash and conjunctival hyperaemia. Laboratory assessments on admission revealed elevated inflammatory markers (value obtained – reference range) (CRP 218<span class="elsevierStyleHsp" style=""></span>mg/L – 0.2–5<span class="elsevierStyleHsp" style=""></span>mg/L; PCT 26.65<span class="elsevierStyleHsp" style=""></span>ng/mL – <0.05<span class="elsevierStyleHsp" style=""></span>ng/mL), acute renal injury (creatinine 3<span class="elsevierStyleHsp" style=""></span>mg/dL – 0.51–0.95<span class="elsevierStyleHsp" style=""></span>mg/dL), anaemia (haemoglobin 10.5<span class="elsevierStyleHsp" style=""></span>g/dL), thrombocytopenia (101<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>platelets/L) and associated coagulopathy (D-dimers 6634<span class="elsevierStyleHsp" style=""></span>ng/mL – 0–243<span class="elsevierStyleHsp" style=""></span>ng/mL). Upon ICU admission, several samples were sent to the laboratory for bacteriological study and SA was isolated from vaginal, nasal, rectal and axillary swabs, pointing out the mTSS as the most probable diagnosis. Blood cultures remained negative. Antibiotic susceptibility testing was performed with Panel Type 33 of MicroScan WalkAway using the breakpoints recommended by The European Committee on Antimicrobial Susceptibility Testing (<a href="http://www.eucast.org/">http://www.eucast.org</a>).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The four SA strains showed the same resistance phenotype (penicillin, erythromycin and clindamycin inducible (MLSBi)); they were sent to the University of La Rioja for detection of (1) virulence genes: <span class="elsevierStyleItalic">tst</span> (encoding TSST-1 toxin), <span class="elsevierStyleItalic">pvl</span> (encoding Panton-Valentine-Leucocidin) and <span class="elsevierStyleItalic">sea</span>, <span class="elsevierStyleItalic">seb</span> and <span class="elsevierStyleItalic">sec</span> (encoding enterotoxins A, B and C); (2) antimicrobial resistance genes (<span class="elsevierStyleItalic">blaZ</span> and <span class="elsevierStyleItalic">ermA/ermB/ermC/ermT</span>); (3) molecular typing (<span class="elsevierStyleItalic">spa</span>-typing and multi-locus-sequence-typing); (4) immune evasion cluster (IEC) system, present in most human SA isolates (the IEC system includes seven different types: from A to E).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The four isolates were typed as MSSA-CC30-t012 and IEC-type A, they carried the <span class="elsevierStyleItalic">tst</span> gene (verified by PCR/sequencing) but not <span class="elsevierStyleItalic">pvl</span> and they carried the <span class="elsevierStyleItalic">blaZ</span> gene (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>); they also carried the <span class="elsevierStyleItalic">sea</span> gene but not <span class="elsevierStyleItalic">seb</span> or <span class="elsevierStyleItalic">sec</span> genes. The prevalence of CC30 SA has been considerably reported in several European countries<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a>; and a study performed in the UK revealed a strong association of the <span class="elsevierStyleItalic">tst</span>-positive CC30 SA lineage with mTSS and TSS cases.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">However, mTSS primarily remains a clinical diagnosis, and indeed, the isolation of SA <span class="elsevierStyleItalic">tst</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">+</span></span> is not required for diagnosis of the disease.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Moreover, in Spain and other countries in Europe, TSS is not a notifiable illness, so the clinical, microbiological, and toxigenic features of TSS remain poorly described.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was empirically treated with cefotaxime and metronidazole. Metronidazole was discontinued and clindamycin was added when SA was reported. After antibiotic susceptibility testing, treatment changed from cefotaxime to cloxacillin and, since the patient was presenting a favourable evolution, clindamycin was maintained. The patient was discharged from ICU setting 2 days after admission, and sent home on the 8th day of hospitalization.</p><p id="par0040" class="elsevierStylePara elsevierViewall">This case evidences the persistence of mTSS cases, which may be fatal, even leading to patient's death.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Thanks to the early diagnosis and the prompt implementation of vital support and antibiotic treatment, our patient had a good outcome.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conclusions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Due to its rarity and initially unspecific symptoms, patients with mTSS are at risk of misdiagnosis. Even though molecular methods are not available in many laboratories, its implementation should be considered since they represent a possibility for faster diagnostics, and to obtain more information for the clinical and epidemiological surveillance of mTSS/TSS-associated SA lineages.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Finance</span><p id="par0055" class="elsevierStylePara elsevierViewall">The experimental work performed in the University of La Rioja was financed by project of MCIN/AEI/10.13039/501100011033 of Spain. R. Fernandez-Fernández has a predoctoral contract from the Ministry of Spain (FPU18/05438).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conclusions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Finance" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Sample \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Molecular typing</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antimicrobial resistance</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Virulence genes \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">IEC-type \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">spa</span>-type \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CC \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Phenotype<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Genotype \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nasal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CC30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PEN, ERY, CLI<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">blaZ</span>, <span class="elsevierStyleItalic">erm</span>(A) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">tst, <span class="elsevierStyleBold">sea</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">t012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CC30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PEN, ERY, CLI<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">blaZ</span>, <span class="elsevierStyleItalic">erm</span>(A) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">tst, <span class="elsevierStyleBold">sea</span></span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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ERY: erythromycin; CLI: clindamycin.</p> <p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleSup">b</span>Inducible resistance.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characterization of the four <span class="elsevierStyleItalic">Staphylococcus aureus</span> isolates recovered from the patient with menstrual toxic shock syndrome.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxic-shock syndrome associated with phage-group-I staphylococci" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. 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| 2024 July | 11 | 9 | 20 |
| 2024 June | 5 | 1 | 6 |
| 2024 May | 5 | 6 | 11 |
| 2024 April | 18 | 7 | 25 |
| 2024 March | 8 | 2 | 10 |
| 2024 February | 9 | 2 | 11 |
| 2024 January | 5 | 3 | 8 |
| 2023 December | 6 | 8 | 14 |
| 2023 November | 14 | 6 | 20 |
| 2023 October | 1 | 0 | 1 |
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