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Toxic Shock Syndrome Following Influenza -- Oregon; Update on Influenza Activity -- United States

Oregon. A case of toxic shock syndrome (TSS) following influenza has been reported to CDC. On December 11, 1986, a 13-year-old white female with fever, hypotension, and acute respiratory failure was seen at an Oregon hospital. Pertinent findings on physical examination included a temperature of 39 C (102 F); blood pressure of 60/0; evidence of upper airway obstruction; and conjunctival, palatal, and lingual hyperemia. A chest radiograph at the time of admission showed a bilateral increase in lung markings consistent with a diagnosis of early adult respiratory distress syndrome.

During the 24 hours following admission, the patient developed a diffuse, erythematous, sunburn-like rash and watery diarrhea. She required both intravenous fluids and vasopressors for treatment of severe hypotension. A diagnosis of toxic shock syndrome was considered and was supported by laboratory findings of thrombocytopenia (70,000/mm((3))), renal insufficiency (creatinine level = 2.8 mg/dL, urea nitrogen level = 40 mg/dL), hypocalcemia (Ca = 5.9 mg/dL), and elevated levels of creatine kinase (12,000 U/L) and aspartate aminotransferase (367 U/L). Staphylococcus aureus was isolated from two tracheal aspirates obtained on the day of admission. Other studies, including vaginal cultures, blood cultures, and urine antigen testing, were negative for pathogenic organisms.

Although the patient's menstrual cycle had begun 6 days before admission, she had not used tampons or other intra-vaginal devices and was not sexually active. However, she had a history of a 4-day prodrome of an influenza-like illness consisting of fever (temperature =40 C (104 F)), malaise, myalgias, sore throat, and substernal chest discomfort.

The patient was discharged following a 10-day hospitalization. On a follow-up examination 20 days after admission, full thickness desquamation of the palms and soles was noted. Testing of acute- and convalescent-phase sera revealed a rise in hemagglutination-inhibition antibody titer to influenza A(H1N1) from 32 on December 13 to 1,024 at the time of her follow-up examination on December 31.

United States. Outbreaks of type A(H1N1) influenza activity are continuing. For the week ending January 31, six western states* and Puerto Rico reported widespread outbreaks of influenza-like illness, and 19 states** and the District of Columbia reported regional outbreaks of influenza-like illness. This is the sixth week with more than 20 states reporting outbreak activity. The level of current activity is below the peak of the previous winter when 37 states reported outbreaks for 1 week in February. Reported by M Brooks, MD, P Bennington, Northwest Kaiser Permanente, D McNeill, Oregon Public Health Laboratory, D Fleming, MD, LR Foster, MD, State Epidemiologist, State Health Div, Oregon Dept of Human Resources; State and Territorial Epidemiologists and State Laboratory Directors; Meningitis and Special Pathogens Br, Div of Bacterial Diseases, WHO Collaborating Center for Influenza, Influenza Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:This 13-year-old girl's illness meets the case definition for TSS (1), which is caused by toxin-producing S. aureus in a susceptible host. The temporal relation between the child's illness and menstruation is most likely coincidental since no S. aureus was isolated from the vagina. The S. aureus isolated from the tracheal aspirates is the most likely cause of TSS in this patient. TSS associated with S. aureus respiratory infections has been reported previously (2). TSS following influenza was first reported last year during an epidemic of influenza type B (3). This is the first case of TSS following influenza reported to CDC this year and the first case reported following influenza type A(H1N1).

The occurrence of TSS following influenza may be coincidental, but S. aureus pneumonia as a complication of influenza is well documented (4,5). Physicians are encouraged to obtain cultures and serologies for influenza in cases of TSS following influenza-like illness or during influenza epidemics. Physicians who have seen patients with TSS following influenza-like illness are encouraged to report these cases through their local and 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.


  1. Chesney PJ, Davis JP, Purdy WK, Wand PJ, Chesney RW. Clinical manifestations of toxic shock syndrome. JAMA 1981;246:741-8.

  2. Wilkins EGL, Nye F, Roberts C, de Saxe M. Probable toxic shock syndrome with primary staphylococcal pneumonia. J Infect 1985;11:231-2.

  3. CDC. Toxic shock syndrome associated with influenza--Minnesota. MMWR 1986;35:143-4.

  4. 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.

  5. Loosli CG. Influenza and the interaction of viruses and bacteria in respiratory infections. Medicine 1973;52:369-84. *Alaska, Idaho, Oregon, Texas, Washington, and Wyoming. **Alabama, Arizona, Arkansas, California, Connecticut, Iowa, Kansas, Kentucky, Minnesota, Mississippi, Missouri, Nebraska, New Mexico, North Carolina, North Dakota, Pennsylvania, South Carolina, South Dakota, and Wisconsin.

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