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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)).

  1. Patients should wash their hands before inserting a subcutaneous needle.

  2. 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.

  3. The needle should be secured to stabilize it at the insertion site.

  4. A sterile dressing should be applied to cover the insertion site. The dressing, not tape, should cover the wound, unless the tape is sterile.

  5. The infusion site and administration set should be changed and a new needle inserted at least every 48-72 hours.

  6. 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

  1. Pietri A, Raskin P. Cutaneous complications of chronic continuous subcutaneous insulin infusion therapy. Diabetes Care 1981;4:624-6.

  2. 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.

  3. CDC. Update: Deaths among patients using continuous subcutaneous insulin infusion pumps--United States. MMWR 1982;31:625-6.

  4. 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.

  5. 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.

  6. Simmons BP, Hooton TM, Wong ES, Allen JR. Guidelines for prevention of intravascular infections. Infect Control 1982;3:61-72.

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