Abstract

PIP: A case report is presented of toxic shock syndrome associated with the use of a contraceptive diaphragm and recent removal of an IUD. A 23 year old woman was admitted to St. Paul's Hospital in Vancouver, British Columbia because of frequent watery diarrhea and vomiting that had begun suddenly 2 days earlier, as well as generalized abdominal and muscular pain, fever and sweating of 1 day's duration. The patient's last menstrual period had ended 3 weeks earlier. Oral contraceptive (OC) therapy had been stopped 9 months earlier, and 2 weeks before admission an IUD had been removed because of dyspareunia. A diaphragm had been inserted 24 hours before the onset of symptoms and was in place at the time of admission. Removal of the diaphragm revealed about 10 ml of greenish yellow pus. Laboratory tests showed multiorgan involvement. The blood urea nitrogen level was 35 mg/dl and the serum creatinine level 2.9 mg/dl. The serum amylase level was 125 IU/l at the time of admission but rose to 1021 IU/l by day 6. The prothrombin time was 16 seconds. Arterial blood gas studies while the patient was breathing room air showed the following: pH 7.36, carbon dioxide tension 20 mm Hg and oxygen tension 84 mm Hg. Urinalysis showed pus and a small amount of glucose. Treatment consisted of blood volume expansion and electrolyte replacement. The patient showed improvement within 48 hours. 6 days after admission an exfoliative desquamating rash developed on the volar surfaces of the fingers and feet, and a slight scaling rash was noted on the face. These cleared spontaneously, without residual scarring. 6 criteria for the diagnosis of toxic shock syndrome have been defined: an increased body temperature; skin manifestations; shock, frequently with orthostatic hypotension and syncope; involvement of multiple organs; diarrhea; and myalgia. Clinicians need to appreciate that tampons are not the only cause of toxic shock syndrome and that the syndrome can occur at times other than during menstruation. Diaphragms may only rarely be associated, but their relation to toxic shock syndrome must be recognized. Counseling on the use of diaphragms should stress the avoidance of prolonged use.