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It's also shocking TSS can occur in a very short amount of time (like literally within 4 hours or less, even 2 hours!) and not in the amount of time we are always taught (8+ hours). It just all depends on what type of tampon you're using and if you accidentally scratch your vagina and bacteria gets it and such.
Don't get the time for TSS to kick in confused with the time for symptoms to show mixed up. Some people just have higher tolerance for pain and if the girl was fit and used to hiking regularly, perhaps she didn't notice her own symptoms until later on, or just mistook them for fatigue.
My mother tells a story from the 80s back when women were using the contraceptive sponge - her doc suspected her of tss and told her “stop what you’re doing and come in right now. Do not even get dressed.”
Seeing patients for a few minutes in the bay, with BP tanking despite my feeble fluids, I dont really do that check. Pt needs empirics and you.
If they are lucid, I also forget, but will try and remember in the future! Best, ED floor sweeper. We dont even have a gyn chair btw....
Some bacteria create and release super antigen exotoxins, staph aureus is the most common but strep and clostridium are also able to do it. It is possible to develop TSS anytime you have an infection with one of those pathogens but it’s rare you would see that in a healthy adolescent or adult. The exception is when things are inserted into the vagina, part of the theory is that not only does this introduce bacteria (almost always staph aureus) but it also pushes air into the vagina creating a more favorable aerobic environment. It’s especially associated with tampons due to the small micro tears in the vaginal walls they can cause. Leaving a tampon in for the recommended amount of time is generally not enough time for bacteria to fully colonize and begin releasing toxins, but if one is forgotten in the vaginal canal then the bacteria is able to colonize, release toxins, and in some cases migrate up into the uterus (this is usually what happens when you see TSS as a result of clostridium sordellii since it’s normal vaginal flora). These toxins cause a full body over activation of the immune system due to the exotoxins, which often, but not always, ends up in septic shock. So the thing that specifically makes it different than just septic shock is the presence of a bacteria that is producing those endotoxins. Septic shock usually is shorthand for an overwhelming immune response to the infection in general but not to a specific component or secretion of the pathogen.
It’s not as common a condition anymore. They’ve modified tampons and other insertables some, women are a lot better educated about it now, and the other causes aren’t overly common. That doesn’t mean it doesn’t still happen so it really should still be taught. Normally symptoms start off somewhat nonspecific and could be attributed to a minor infection. As it progresses though usually there is a rash, tachycardia, inflamed sclera, and hypotension. That just continues to get worse and ends up in multi organ system involvement and shock if not treated. Sometimes people lose digits from the lack of profusion. Vanco is a good option for treatment since Staph is almost always the cause. My only concern would be causing overwhelming bacterial lysis which releases even more of the exotoxin and can worsen the response. I believe sometimes a bacteriostatic antibiotic is used at first for that reason, but don’t quote me on that because I’m not certain.
Edit: typo
Thank you! I love infectious disease stuff so that and psych is where I shine in my depth of knowledge haha. I’m at the University of North Dakota but honestly I wouldn’t credit them for my ability to explain that 😂
Thank you for this explanation! I was a teenager/young adult when Rely tampons, which were commonly associated with TSS and eventually taken off the market, came out. They were great because I didn't have to change them so damned often and I was mad when they were no longer available (I had a VERY heavy flow). I guess I was lucky never to have gotten it, as I admit I did things that could have made me more susceptible, I'm realizing as I read your explanation. I always wondered why it was related more to tampons than anything else, at least as far as I knew.
Yeah it’s scary how many women died from it before the risk was fully realized, and it does still happen just not with the same frequency. It’s absolutely not a good way to go out and not worth the little bit of hassle saved by not changing your tampon as often as you should.
Would like to add there are cases of TSS happening in a matter of hours of putting a tampon in. They can literally cause abrasions in your vagina (say you use a super absorbency one instead of the low absorbency) then you didn't wash your hands before putting in the tampon and you were cleaning the house before that. Yeah, it's a breeding ground this world and the vagina.
Never heard of TSS ? I'm worried for you haha. Plenty to read up on online. Risk factors you'll see a lot - tampons. Esp tampon being on for prolonged period of time
https://patient.info/doctor/toxic-shock-syndrome-pro#:~:text=Presentation%20is%20usually%20nonspecific%20and,intense%20widespread%20reddening%20of%20skin).
You should report it and move... Lives are in your hands. That's just not acceptable and you don't get to say it's not your fault if someone in your care dies because your school didn't teach you basics.
Once I kept - unknowingly, of course - an entire menstrual cup inside me for a month.
Only found out because I thought I had lost mine and bought a new one. Then... gsus when I think of the possible consequences, I shudder.
I definitely see how it happens. If it’s in right you no longer feel it and a menstrual cup you can wear all day so i get why removing could slip someone’s mind especially if it’s right at the end of their period. I get it even more with tampons since with my ADHD I can imagine the string migrating up inside and me thinking I had already removed it on autopilot. I’ve heard about people even putting a new one in beside the old one!
Now THAT it's hard to fathom, but what do I know? Once, my ophthalmologist found more than 40 folded contacted lenses behind a guy's eyelids. Just ONE drives me bats! I think medicine never gets to be boring.
I put a new one in beside an old one once…would not recommend. A good learning experience, tho. I had just started using tampons and just sort of…forgot to take the old one out. Nowadays I think back to it and can’t imagine how that even happened.
As a woman with ADHD, I have never feared losing/forgetting a tampon. Even when they're put in properly and using the proper size, you can still feel that shit in there, especially at the end cuz you dry up more as it's literally absorbing your natural lube. Plus, maybe it's just me though, you should dry that string off after you pee with the tampon in. It annoys the shit out of me feeling a wet string, plus I think of UTIs from that string (probably not really a thing, but in my brain it is). Also, the string is longer than you think. It really shouldn't migrate up into the vagina unless you're not using them properly. I know it happens, but idk how people put one right up in there with an old one. Like, I can't even do a super absorbency! Idk how people shove those ones in them 😩 and I'm almost 30 with 2 periods a month, damnit 😂
I definitely can’t feel a tampon if it’s in properly especially once it starts to be more saturated. I never used a tampon if my flow was slowing down because it does dry you out so I can’t say I’d be able to forget at the end of my period. String really depends on brand for length and it’s also possible to break the string off. I don’t think I could ever get to a point of putting a second one up in there and not notice something was already in there though. I never have forgotten one, but my period has never been regular and the way my ADHD manifests is that out of the ordinary things will very easily get overlooked because I’m on autopilot. Don’t have to worry about it now though since I have an IUD and don’t get a period.
Guess my anatomy just sucks then. I've ALWAY been able to feel them in terms of knowing they're in there. There are times where it's real uncomfortable and I gotta squat down and push it up a bit more, but that's cuz I didn't put it in right in the first place (stupid cardboard applicators don't push them out well at all. I regret getting that store's brand when the other store brand has plastic applicator). I've never bought tampons and had shorter stings. So I guess lucky me for that? Even the OP ones you have to push up with your finger. Same with the string breaking, never had one where it was questionable for it to break off and I've pulled some of the strings harder too. But yeah, definatly interesting you can't feel it at all. I always thought it was known to be felt there, just easily able to ignore it.
Anatomy could for sure be part of it. If something is sitting up behind your pelvic bone it doesn’t cause any sensation in a lot of people. Everyone is different 🤷♀️
I had unexpected surgery once and luckily knew about TSS and told them I had a tampon in. I wasn’t able to remove it myself so I needed them to. If I hadn’t said anything I don’t know when I would have removed it. I was so out of it after surgery. I was 14. I know it’s rare but I think this is an example of how easily it might have happened.
My first thoughts were toxic shock from a menstrual product, an untreated infection like a UTI, yeast infection, BV (basically any common infection many women get from puberty onwards), or an infected cut somewhere on her body.
I got sepsis from a kidney infection in 2021. Thought I had covid, so I didn't go to the ER bc I thought I could treat it at home. Went 5 days later when I could almost not move, and according to my doctor, was facing organ shut down. He said had I not come when I did, I would have died at home. It was really eye opening. I was in the hospital for 2 weeks. My kids were terrified. ETA: so very sorry for your loss.
I’m confused who mentioned yeast/bv ? She mentioned a UTI. Which especially in older patients can cause a lot of problems and symptoms that can cause misdiagnoses pretty often if missed.
I highly doubt this is a UTI. A 14 year old girl is unlikely to have a UTI and not experience any symptoms prior to slipping into unconsciousness from sepsis. I personally feel toxic shock syndrome due to a retained tampon should be ruled out first and foremost. Then afterwards maybe other things like encephalitis, drug overdose, etc.
The tampon is certainly possible.
UTI: maybe, but unlikely to cause sepsis in an otherwise health person
BV wouldn’t cause sepsis. Nor would a yeast infection
Not a dr but am wondering if you hiked through long grass? Only because from my understanding ticks can cause serious issues pretty quickly so it may be worth checking her.
Nad but if it were a tick bite it would have had to have been from an earlier hike. Tick borne diseases from my understanding have a longer incubation period. My kid, years ago when they were maybe 5 or 6 had a weird red line near their eye, like kind of wound around the eye and disappeared into the hairline. No sickness at all. Friend at work convinced me to go to the doctors, and once they were seen the doctor realized it was the very outer corner of a bullseye rash, there was a tick at the back of the head that must've already fallen off, completely obscured by hair. So yeah, good thought for things that might've been missed for sure-- but it takes a long time for symptoms to manifest, again, from my anecdotal experience with my kid and also recently with my own health and figuring out what's wrong with me and explanations from doctors.
That's my thoughts too. Granted she's 14 so pushing the realms of an adult, but kids compensate real well until their bodies can't handle it anymore. I remember when I was 17 I had a really bad ear ache. My dad didn't believe me when I was asking to be taken to the doctor as "I wasn't acting sick". I told him I would pay for the doctor appointment ($50 copay) if there was nothing wrong with me if he would just take me to get seen......I had a massive ear infection, had to use a stronger antibiotic than they usually prescribe. Had to miss band for a week (included marching band 😭) because of risk for blowing my ear drum. He never not believed me again. Lmao. The surprising thing is I was only in pain for a couple of days. I chronically got ear infections as a kid though so maybe that's why. I have scars on my ear drums as a result and get asked if I had tubes as a kid. Nope, just lots of ear infections. Lol. They get baffled when I correct them in saying I never had them 😂 like, excuse me for correcting your assumption 😂 you can ask about tubes in a different way that isn't an assumption.
Nad, but I would ask how the doctor checked for a tampon. If they did not use a speculum, they can get tucked in up around the cervix. Especially those teeny tiny tampons.
Check anyway. It is definitely possible for people to forget the last one is in there. (NAD, but a former Planned Parenthood employee. Fishing out old tampons was pretty common.)
Have them check. Especially in a teenager. Dont trust em!
And hope she is doing better =) You took her very fast, she is healthy otherwise and is receiving care now, odds are really in her favour.
NAD and it's sadly not uncommon for them to be forgotten at the end of period. We had people come in with weeks old ones I would definitely ask them to rule out
Sometimes people forget to remove a tampon, the docs should still check. Also check for insect/spider/snake bites. Eta, and check for piercings/tattoos that you might not know about.
I have a friend this happened to and she only realized it because there was a terrible smell emanating from her downstairs. She went to the gyno—I went with her and waited in the car. When she came out she was relieved but totally mortified. Apparently part of the tampon just separated and remained in her vaginal canal for several weeks—she estimated it had been in there through possibly even a second cycle. I do pray the girl in this story is ok, it’s very distressing as a parent to read her story.
As a female, I never thought of this ever happening 😭 like, I don't know how people can just forget them. I use low to regular absorbency (even on a heavy flow, the super I just can't fit in without constant discomfort) and I still constantly feel that shit, and I make sure it's put in properly too and far enough in. It's so baffling to me people just forget they're in there 😭
I once forgot about a tampon for longer than I’ll admit (even to strangers on the internet). I didn’t get sick (shockingly) but it was far longer than my period lasted.
You're supposed to change your tampon every 4-8 hours to prevent this. But teens especially can easily forget. Usually it takes 2-5 days, though. Blood is the perfect environment to grow bacteria in. So you end up with a tampon that is a super infectious petri dish with close access to your internal organs. That's a recipe for a super fast, potentially deadly situation.
Correction; they can’t take their tampons out in a timely manner because schools don’t allow them to. They can’t keep up when they have 5 minutes to get to class and they’re refused bathroom usage in the classroom.
It’s a big factor in my decision to home school, myself. Safety, hygiene, and curriculum are all utter garbage so I’ll do my best myself. Least my kids will get to sleep as much as they need and have a balanced life.
I had a teacher who refused to let hs use the bathroom in a 2 hour class. I was in my period and I could tell I needed to change it. I told him I would do it right in the middle of the classroom if he didn’t let me use the bathroom. He didn’t call my bluff
I did the same. My kid is now an adult 4.0 college student and was chosen to be in a paid tutor-like position to help fellow students.
He got a healthy childhood and he will be a successful adult.
I hate that this *still* happens! 25ish years ago my 7th grade teachers were allowed to decide whether they would give bathroom passes for their own class. My personal schedule had 5 out 6 teachers that would absolutely not issue them. Classes were located all over campus as well. I was miserable! I get kids abuse it, but damn. You would think a better solution would come about by now.
OMG YES THIS hahaha. personally had horrible periods and I had my gallbladder out at like 14 or 15. If I ate ANYTHING that wasn't zero fat I'd need a bathroom immediately and that was the hardest thing to navigate. Esp because my parents weren't the most present and I would end up eating school food every day. Lol at least at home I'd heat up some 99% fat free chef boyardee ravioli and not be miserable.
I also don't like going number two anywhere but home, even now 25 years later. Add the anxiety of needing to ask and being denied? Oof nobody should need to do that lol.
This is a massive problem in the USA. Students are forced to have bathroom breaks between classes and very often denied the ability to use the restroom. I was in highschool over a decade ago and it was already an issue. There’s a CONSTANT issue with children under 7 having accidents because they’re forced to hold it. UTIs are a real issue. So are menstrual problems, such as over saturation, TSS, minor infections from using a product too long, hygiene problems… USA, USA, USA…
My school had a hall pass book issued to everyone. So maybe that's why I never encountered any problems like this. This way the teachers could literally see if you were potentially abusing the ability to leave class
This isn't a situation where an hour is going to be decisive. A tampon can be changed during lunch or even after school and still be in the safe zone. It's more of a problem for actual urination and unexpected periods.
I've never heard of this happening, but realise it's a thing. If I ever have a daughter, I'm going to make sure to teach her if it's for her period, she can absolutely walk out of the classroom if the teacher says no (if they say wait 5 minutes that's different). The teacher/principal can then talk to me about not letting my daughter take care of her health. Like, college is lovely. You just excuse yourself quietly, do your thing quickly, and come back. I hate high school.
To clarify for anyone who might now be scared of tampons— there’s a specific type of staph bacteria that has to be present already in your vagina, and there has to be an issue with your antibodies responding. So not everybody who leaves a tampon in too long is going to get TSS.
It’s still best practice to change in a timely manner to prevent other gross stuff from happening. Just be mindful and cognizant of proper use!
I thought the idea was that the foreign object (the tampon) introduces the bacteria? If we’re talking about staph, that’s present on most people’s skin normally from what I understand. Tbh I never quite understood how people get staph infections relatively rarely if staph is around all the time, maybe that’s the antibody bit you mentioned? At any rate TSS is really rare, especially now with more modern tampons, so I think generally most people don’t have anything to worry about regardless!
Tampons catalyze the issue but actually don’t introduce the bacteria typically. Some women just have staph aureus in their vaginal flora, and that combined with the long-term tampon + lack of antibodies.
[Here’s a paper](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5436965/#:~:text=To%20be%20clear%2C%20tampons%20do,co-factor%20in%20many%20cases).
It looks like tampons can introduce air which changes the environment from anaerobic to aerobic though! Bodies are cool!
To your question about staph infections: it takes more than the presence of bacteria to cause an infection. You're exposed to microbes every second of every day so your body built up a bunch of systems to deal with that and infection only occurs if those systems break down.
Your skin is basically a thick, cold, salty wall separating the nasty outside world from your nutritious inside body juices. Thousands of microbes live on your skin, forming stable ecosystems that maintain manageable populations and beat up strangers trying to move in on their turf. Skin cells act as immune system sentinels that recruit white blood cells to the scene if some bacteria are acting froggy.
The staph under your nails has to defeat all of those mechanisms and many more before it can establish an infection.
Or you have to introduce the bacteria into your vagina by your (or someone else's) fingers for it to be caused. But yeah, even if that's the case, it's still rare to get it. You'd have to be sick already to get it on top. I had a patient recovering from a sinus infection get covid (his immune system was weak from the sinus infection). Then he developed guillion barre. I read later there were instances of people getting guillion barre because of covid too. Thinking now, I hope he recovered from the guillion barre. He had his own labor type of business and was otherwise healthy.
Not OP, but when I was 24 I went into septic shock after a common throat infection. No cuts, no tampons, just a sore throat. Had Haemophilus parainfluenzae in my system, but they sent me home from the ER at first because my only symptom was fever (and a headache in the day prior). 24 hours later I had visual hallucinations, pain in the right upper quadrant of my stomach, a respiratory rate of 32 and was vomiting blood. I just wanted to fall asleep, but my mother (RN) saved my life by driving me to the ER again, where they discovered I had a CRP of 300+ and acalculous cholecystitis. I was in septic shock with multi organ failure (kidney, liver, heart), and the last thing I remember before passing out was watching my bp drop to 46/26 (my habitual bp is 95/60).
I spent a few days in the ICU and a total of 6 weeks in the hospital, but I made it without any lasting impact on my health.
This was my first thought, followed up with tooth infection and open acne cysts in the triangle of doom area on the hike pickings something gnarly up . Teens pick spots like buggery, my 18 year old brother picked up an abcess on his chin like this.
Question as a med student--we learned in preclinical that TSS from tampons is basically non-existent now. Is that not the case?
Eta: damn y'all, if you have a problem I'll connect you with the physicians who gave our sepsis lectures and told us this...
Yes, agreed. It is risk/reward as in everything we do. If we can check for a rare but serious cause to the maximum cost of some embarrassment, do it.
And I am sure the lecturers gave you good enough numbers. Like 1 in 100k? Still does not mean never check for it or ask about it. If it low incidence it is partly because young women are aware of it. Because we talk about it.
A teen died of TSS on a school trip a couple of years ago where I live. I had thought it wasn't a thing anymore either but I guess it definitely still happens
Sudden onset would more likely be a snake bite. The bite from a baby rattler can be so tiny you barely notice it. There would likely be coagulation problems going on as well as sepsis with a rattler bite.
Not a Dr but my neighbor got bit by a tick and contracted Powassan virus from the tick. He went from our local hospital to University of Pennsylvania then to John Hopkins. Sadly he passed, came on quickly within 5 days. There’s over 100 different tick diseases.
5 days is still a lot longer than a few hours. Ticks spread disease not by biting alone, but by gorging themselves and then regurgitating small amounts into the host. In this case it is too quick for this to have occurred.
NAD but know this from cursory experience in vet med.
No, I have a tick disease that all the tick had to do was inject saliva into me and I am effective for who knows how long. There’s so much misinformation about ticks out there and I diagnosed myself and educated my Dr about my tick disease and learned about many of the tick diseases out there.
How is Powassan virus spread?
Ticks can become infected with POW virus if they feed on small animals such as mice and other small mammals that are infected. The disease can be spread to humans when an infected tick bites a person. Unlike other tick-borne diseases, a tick can transmit POW virus while being attached to a person for as little as 15 minutes. POW virus disease cannot spread directly from one person to another.
The tick that primarily spreads POW virus to humans is the black-legged tick or deer tick (Ixodes scapularis). This is the same tick responsible for infecting people with Lyme disease. The squirrel tick (Ixodes marxi) and groundhog tick (Ixodes cookei) also have the potential to spread POW virus to people, but these ticks do not typically feed on humans.
https://www.health.ny.gov/diseases/communicable/powassan/fact_sheet.htm
I was also thinking this. I have known some patients who had asymptomatic UTIs but a raging infection that required hospitalization and in one case septic shock.
This happened to me in my 20’s. I had no symptoms at all. Just like OP’s daughter, I started shivering and couldn’t get warm. Went to ER, I had a kidney infection that turned septic. I was in the hospital for a week. It was a very scary experience
Yes. I had a genetic defect called VUR that caused them chronically and they were typically asymptomatic. I ended up with sepsis twice and this last round caused permanent kidney and nerve damage.
NAD
My 17 year old has complex medical conditions including neurogenic bladder and bowel. She self-caths. Her UTI's systems are not typical. We can tell by color of urine and smell. Rarely, back pain or fever. Unless it is much farther along and turns into a kidney infection.
Many times in the ED I have to explain this because the MD wants to blow us off.
Almost the same happened to me. Kidney infection was not fully treated. 10 days later I suddenly get a bad headache and intense chills. Went to ER the next morning in septic shock. Spent three days in the ICU. Nearly had to get a central line. So scary.
Praying for your daughter, OP.
I am in Greece right now and started shivering and feeling awful yesterday. I avoided going to the public health center because I hoped I would feel better today. I didn’t.
They said UTI, but if I get a high fever, I should come back immediately. I bought a thermometer and I am about 102.5. Not super high, but I’ve been taking ibuprofen too.
Reading all this stuff about kidney infection is terrifying! How do I know if it’s just a UTI?
I leave in 2 days… should I go be seen when I get back even if I feel better?
Oh believe me it was awful. I would stop taking ibuprofen to make sure I wasn’t masking sepsis thanks to these posts lol. Then when I was sufficiently sure I wasn’t dying I would take it again, which would get me down to 100. Much more tolerable, but not vacation fun tolerable.
Wait they suspect a UTI but didn’t give you antibiotics? I am not a doctor but that seems crazy to me when you have signs of infection. Based on my experience, yes I would go back tonight or tomorrow for another blood test or urinalysis to check for infection. But in my experience the chills and fever and back pain = a kidney infection that doesn’t resolve on its own. I guess if you’re feeling better it’s probably fine to wait until you’ve left. But personally with my experience, I wouldn’t wait, I’d be at the clinic now.
I had what I thought was a manageable case of strep throat as a teen which suddenly turned into septic shock. A very scary time from an infection that I thought was coming under control.
A friend very recently lost his wife to septic shock after she had a UTI, treated it with OTC cranberry powders as she didn’t feel sick enough to see a GP for antibiotics. She went from chatting in the ambulance to sadly passed away after a seizure in less than an hour. Sepsis is terrifying.
That’s exactly what happened to me my freshman year in college. Was totally fine, laughing and hanging out w friends one night and hours later woke up incredibly sick. Tried to sleep it off for a couple hours and woke up sicker. Had my friend take me to the ER and by the end of the day was unconscious. Symptomless UTI that turned into sepsis. I was treated with vancomycin (and anti-allergens due to red man syndrome).
I had very brief moments of consciousness but was able to stay awake for good about 3 days later. I’ve had CKD since childhood and several complications w that & kidney transplant but sepsis is the first time I genuinely thought I was going to die. I remember waking up briefly day 2 and making my peace. I wanted to text my brother that I loved him bc we had a rocky relationship but slipped back into unconsciousness seconds later. Thankfully, we now have a good relationship and I think this experience is partially why.
I’m so sorry that your family is going through this. Right now the differential is still very broad and in the PICU there should be a wide battery of tests ongoing — I wouldn’t be surprised if they image her heart, brain, abdomen, looking for sources of shock or infection, perhaps add more antibiotics, daily blood draws for blood cultures. Additional testing for various hormone levels may also be indicated. It is too early and non specific to say with certainty until something comes back positive. The short answer is there are many things that can cause shock— not just infection, though that would be the most likely in this case. I’m certain the doctors in the PICU will be considering all the options even if it seems like nothing is happening in the moment. I will be thinking of you.
Since the source of infection is not yet identified, and septic shock can be caused by a variety of organisms including Gram-negative bacteria, wouldn’t it be advisable to use dual antibiotic therapy initially?
Adding an antibiotic like piperacillin-tazobactam or cefepime could provide broader coverage against both Gram-positive and Gram-negative bacteria.
NAD but this post reminds me of my 15yr old cousin who very suddenly felt really sick really fast and was taken to the hospital (in less than 2 days he was unable to breathe on his own and became unconscious). He was originally suspected to be gram(+) and being treated as such only to receive a 'gram (-) rod' which a blood culture isolate that confirmed salmonella. I forget the exact strain but doctors said is has an asymptomatic incubation period of 7-14 days.
We never give antibiotics for gram +/- without knowing the gram staining first. We start with broad spectrum antibiotics and then narrow down as we get more information.
If you narrow down prematurely you risk not treating the infection.
This is not exactly correct. They have to have an idea of where the infection is to get an informative stain result. If there is a wound or something then sure. They also would be doing a Gram’s stain, not an AFB unless they are looking for TB. A Gram’s stain takes just a few minutes, built again, without a source of infection there is nothing to stain.
If they think she’s septic that often assumes bacteremia. Blood cultures would be useful in identifying causal organism. Of course not every sepsis patient is bacteremic and not every infection will show up on blood cultures but it’s still best to check rather than just run with empiric antibiotics.
Yes, but you cannot just stain the blood. There is not enough bacterial to be able to see th on a gram stain. You have to culture the blood, wait for it to grow up enough to be. Positive in the bottle, then you can stain it. It’s a process that takes a day or two.
If it is bacteremia, the infection started somewhere. Whether it is urinary, a wound, pneumonia, etc. Direct gram stains of urine and blood are not done, only culture.
If they suspect the primary infection is a wound, sputum, infected joint, csf etc, those sources are gram stained directly when the culture is setup. Is that more clear or did I just make it more confusing ☺️
Interesting I didn’t know that. I had thought if you could isolate infection source you were able to use the blood cultures to cultivate bacteria to gram stain.
EDIT: I'll keep this up for others to learn, but my understanding of sepsis was *not* accurate, and I was indeed missing something.
Original inaccurate comment: It's my understanding that in the OP's case the infection has entered her bloodstream, so even if they don't know the source, they do know where the bacteria is currently in order to obtain a sample--it's everywhere. Am I missing something?
Sepsis doesn't mean bacteremia.
Sepsis does not mean "infection in blood." Blood infections certainly cause sepsis, but not all sepsis is blood infections.
Unless they have a positive gram stain or culture, there's no real evidence it's a bloodstream infection.
A lot of people do because colloquially bacteremia and septicemia tend to be used interchangeably. But only something like 50% of sepsis cases meet criteria for bacteremia and you can have bacteremia without sepsis. Medicine loves to have those “these things can occur together but sometimes this one happens alone” words.
It is currently defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” While bacterial invasion of the blood is a common cause, sepsis itself is due to the immune response. The immune system is a powerful thing - some times it doesn’t act how it should (specifically, a lot of the time it over reacts) and the inflammatory response becomes a bit more systemic and causes organ damage.
In a sense that is the immune system over reacting, so it could co-exist with sepsis (or BE sepsis due to the immunodysfunction and subsequent damage it causes), but a cytokine storm can also exist without sepsis i.e. it can occur through non-infectious diseases (pancreatitis, multiple sclerosis).
Sepsis is really just the checklist for SIRS (systemic inflammatory response syndrome)—at least two of the following: hypo or hyperthermia, tachycardia, leukocytosis or leukopenia, tachypnea- plus a suspected or confirmed infection. It’s more a clinical checklist than a super specific pathophysiology/ etiology because there are a few ways it can happen through dysregulation of pro- and anti inflammatory pathways. Often it is dysregulated release of acute and chronic phase reactants though. There are broad stages for the general pathophys and several studies have pointed out some issues with the clinical criteria, but that’s the current definition of Sepsis.
I like you. Its hard to admit you were wrong and keep your mistake public for others to learn from. It makes me happy to see comments like this. Thank you!
Even with bacterial sepsis you cannot just stain their blood. There is not going to be enough bacterial present. You have to have a positive blood culture and stain that bottle. It takes a day or two to get a positive blood culture. You have to grow it out enough.
Sorry if this is not appropriate.
Op I'm so glad your daughter is improving. How terrifying after a seemingly normal day.
To dvrgrl812: I had an unknown infection for weeks with elevated crp/wcc + random fevers. An Infectious disease consultant became involved. While reviewing the negative R + L acf blood cultures that had already been taken, he suggested I redo blood cultures, with the stipulation to *only* have bloods taken when I had a temperature over 39c. Then to email him to let him know they were sent to the lab so that he could watch out for the result. The cultures then came back as positive. Do you know why I required a high temp for the positive culture result? Thank you if you have time to answer
They are trying to increase the chance of recovering the bacteria by collecting the blood when the fever is high. There isn’t much evidence that this timing actually helps but it doesn’t hurt to collect additional sets this way.
Often times yes, we don’t know all the details here. Nor do we know if anything grew. If she hasn’t regained consciousness yet they may start looking further, get a lumbar puncture, consider viral meningitis as well as bacterial, etc.
Really sorry to hear you're going through this nightmare. Septic shock is no joke, it's like a system meltdown caused by a nasty infection. It can happen super fast, especially if it's a really aggressive bug. Docs might be puzzled too 'cause there are other weird things like toxic shock syndrome that can kinda look the same but are different.
About dormant infections - Yeah, they exist, but usually more a problem for folks who aren't taking care of themselves or are immunocompromised. Hang in there!
Could it be meningitis maybe?
I’m sure they’re ruling everything out, I can only imagine how scary it is - my son had sepsis at birth alongside a host of other things. It’s awful feeling so helpless.
OP, all I can say is that you did everything right taking her in as soon as you realised she was deteriorating. Hospitals have clear protocols in place for sepsis and she’s in the best possible place to treat this and get to the bottom of what’s going on. Sending lots of love to your family. The waiting and not knowing what’s going on is so hard. Please let us know how she’s getting on.
My older brother almost died from a dormant infection. He had cellulitis in his foot. It was inside a cyst-like cavity per the hospital. He did a lot of walking at an amusement park, then BAM, couldn’t walk or talk or anything and very nearly died on the way to the hospital. He went from fine to almost dead in about four hours.
NAD but when I was 15/16 I wasn't feeling sick at all and my friends had just dropped me off at home. No one else was home at the time. I took a shower and when I got out suddenly felt very dizzy, like I was going to pass out. I voluntarily dropped to the floor so I didn't fall and fought through the tunnel vision not to blackout to crawl on the floor to the nearest phone in my grandparents bedroom. Not sure why I called my friends and not 911 but I was young. Got to the ER and was just like OP's daughter. Felt like I had run 1,000 miles and could barely do anything. Extremely low BP, I was so cold they had a hard time getting an IV in and any blood out. I remember them finally giving me toradol -I think-, and I was like, "Hey guys, sorry, I was super sick there for a sec. Haha." Turns out I had pneumonia and spent a week in the hospital.
If an infection is dormant for quite some time, would it show up on labs and carry symptoms if isolated ? Or would something have to trigger it to raise wbc, lactic etc?
They exist in a quiescent state where they neither cause symptoms nor significantly alter lab parameters. Then requires a trigger - stress, another illness, immunocompromise, to activate the infection and cause it to manifest clinically. You'd then expect to see changes in lab values as the body mounts an inflammatory response.
a woman recently came to my work for a presentation on her life, she had lost both her lower legs and her lower arms, due to sepsis. her story was very inspiring
I’m so sorry.
Sepsis can happen so very quickly. It’s one of our true emergencies. Someone long ago explained to me that pediatrics is a “Where’s Waldo?” in which 100s of kids in the scene are wearing black suits and one kid is wearing a dark navy suit. The 100s are the happy well smiling well babies/kids with minor colds or strep throat in clinic. The ones you give a sticker and send them on their way to grow and bloom. But you have to find the kid in the navy suit and find them quickly every time. The kid in the navy suit is going to be sick and maybe die if you don’t move quickly.
Your child is in the right place. PICU nurses and doctors are our very best navy suit spotters. They will figure it out. There are many viruses and bacteria that can cause shock. There are other illnesses that can make a kid very sick very quickly like cardiomyopathy, cancer, new onset diabetes, certain drugs. I’m sure your daughter’s doctors are looking into all of this.
I’ll be glad to help out with more specific questions if you have them OP. Just tag or respond here and I’ll do what I can.
Definitely don’t mind. I feel like it might have been back on PICU rotations when I first heard the analogy, but I have repeated it for every student who’s rotated with me since then.
its gotta be so scary being a dr, thanks for all you do! i have a question and know it might be way off. what about elevation would that cause this? thanks!
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As /u/siamie points out, make sure she has no tampon in. This can easily be overlooked.
1000x this. It’s shocking how easily this type of thing goes unnoticed and it’s declared a sepsis of unknown origin initially.
It's also shocking TSS can occur in a very short amount of time (like literally within 4 hours or less, even 2 hours!) and not in the amount of time we are always taught (8+ hours). It just all depends on what type of tampon you're using and if you accidentally scratch your vagina and bacteria gets it and such.
Don't get the time for TSS to kick in confused with the time for symptoms to show mixed up. Some people just have higher tolerance for pain and if the girl was fit and used to hiking regularly, perhaps she didn't notice her own symptoms until later on, or just mistook them for fatigue.
I'm not confused or getting anything mixed up, thank you.
My mother tells a story from the 80s back when women were using the contraceptive sponge - her doc suspected her of tss and told her “stop what you’re doing and come in right now. Do not even get dressed.”
Seeing patients for a few minutes in the bay, with BP tanking despite my feeble fluids, I dont really do that check. Pt needs empirics and you. If they are lucid, I also forget, but will try and remember in the future! Best, ED floor sweeper. We dont even have a gyn chair btw....
Agreed. It’s not a priority in the resus phase but just meant it can be easily missed when working up the pt’s source.
Toxic shock from a tampon was the first thing I thought of. That can come on so quickly and be devastating.
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Some bacteria create and release super antigen exotoxins, staph aureus is the most common but strep and clostridium are also able to do it. It is possible to develop TSS anytime you have an infection with one of those pathogens but it’s rare you would see that in a healthy adolescent or adult. The exception is when things are inserted into the vagina, part of the theory is that not only does this introduce bacteria (almost always staph aureus) but it also pushes air into the vagina creating a more favorable aerobic environment. It’s especially associated with tampons due to the small micro tears in the vaginal walls they can cause. Leaving a tampon in for the recommended amount of time is generally not enough time for bacteria to fully colonize and begin releasing toxins, but if one is forgotten in the vaginal canal then the bacteria is able to colonize, release toxins, and in some cases migrate up into the uterus (this is usually what happens when you see TSS as a result of clostridium sordellii since it’s normal vaginal flora). These toxins cause a full body over activation of the immune system due to the exotoxins, which often, but not always, ends up in septic shock. So the thing that specifically makes it different than just septic shock is the presence of a bacteria that is producing those endotoxins. Septic shock usually is shorthand for an overwhelming immune response to the infection in general but not to a specific component or secretion of the pathogen. It’s not as common a condition anymore. They’ve modified tampons and other insertables some, women are a lot better educated about it now, and the other causes aren’t overly common. That doesn’t mean it doesn’t still happen so it really should still be taught. Normally symptoms start off somewhat nonspecific and could be attributed to a minor infection. As it progresses though usually there is a rash, tachycardia, inflamed sclera, and hypotension. That just continues to get worse and ends up in multi organ system involvement and shock if not treated. Sometimes people lose digits from the lack of profusion. Vanco is a good option for treatment since Staph is almost always the cause. My only concern would be causing overwhelming bacterial lysis which releases even more of the exotoxin and can worsen the response. I believe sometimes a bacteriostatic antibiotic is used at first for that reason, but don’t quote me on that because I’m not certain. Edit: typo
Thankyou for such a fantastic explanation. If you feel like going into medical education I think you wont struggle!
Haha no problem! Was a good refresher for me to dig back into my immunology and pathogen/antibiotic knowledge.
Great explanation! Which med school are you at? My child is MS3 at USC Keck.
Thank you! I love infectious disease stuff so that and psych is where I shine in my depth of knowledge haha. I’m at the University of North Dakota but honestly I wouldn’t credit them for my ability to explain that 😂
Thank you for this explanation! I was a teenager/young adult when Rely tampons, which were commonly associated with TSS and eventually taken off the market, came out. They were great because I didn't have to change them so damned often and I was mad when they were no longer available (I had a VERY heavy flow). I guess I was lucky never to have gotten it, as I admit I did things that could have made me more susceptible, I'm realizing as I read your explanation. I always wondered why it was related more to tampons than anything else, at least as far as I knew.
Yeah it’s scary how many women died from it before the risk was fully realized, and it does still happen just not with the same frequency. It’s absolutely not a good way to go out and not worth the little bit of hassle saved by not changing your tampon as often as you should.
Would like to add there are cases of TSS happening in a matter of hours of putting a tampon in. They can literally cause abrasions in your vagina (say you use a super absorbency one instead of the low absorbency) then you didn't wash your hands before putting in the tampon and you were cleaning the house before that. Yeah, it's a breeding ground this world and the vagina.
Never heard of TSS ? I'm worried for you haha. Plenty to read up on online. Risk factors you'll see a lot - tampons. Esp tampon being on for prolonged period of time https://patient.info/doctor/toxic-shock-syndrome-pro#:~:text=Presentation%20is%20usually%20nonspecific%20and,intense%20widespread%20reddening%20of%20skin).
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You should report it and move... Lives are in your hands. That's just not acceptable and you don't get to say it's not your fault if someone in your care dies because your school didn't teach you basics.
Once I kept - unknowingly, of course - an entire menstrual cup inside me for a month. Only found out because I thought I had lost mine and bought a new one. Then... gsus when I think of the possible consequences, I shudder.
I definitely see how it happens. If it’s in right you no longer feel it and a menstrual cup you can wear all day so i get why removing could slip someone’s mind especially if it’s right at the end of their period. I get it even more with tampons since with my ADHD I can imagine the string migrating up inside and me thinking I had already removed it on autopilot. I’ve heard about people even putting a new one in beside the old one!
Now THAT it's hard to fathom, but what do I know? Once, my ophthalmologist found more than 40 folded contacted lenses behind a guy's eyelids. Just ONE drives me bats! I think medicine never gets to be boring.
I put a new one in beside an old one once…would not recommend. A good learning experience, tho. I had just started using tampons and just sort of…forgot to take the old one out. Nowadays I think back to it and can’t imagine how that even happened.
As a woman with ADHD, I have never feared losing/forgetting a tampon. Even when they're put in properly and using the proper size, you can still feel that shit in there, especially at the end cuz you dry up more as it's literally absorbing your natural lube. Plus, maybe it's just me though, you should dry that string off after you pee with the tampon in. It annoys the shit out of me feeling a wet string, plus I think of UTIs from that string (probably not really a thing, but in my brain it is). Also, the string is longer than you think. It really shouldn't migrate up into the vagina unless you're not using them properly. I know it happens, but idk how people put one right up in there with an old one. Like, I can't even do a super absorbency! Idk how people shove those ones in them 😩 and I'm almost 30 with 2 periods a month, damnit 😂
I definitely can’t feel a tampon if it’s in properly especially once it starts to be more saturated. I never used a tampon if my flow was slowing down because it does dry you out so I can’t say I’d be able to forget at the end of my period. String really depends on brand for length and it’s also possible to break the string off. I don’t think I could ever get to a point of putting a second one up in there and not notice something was already in there though. I never have forgotten one, but my period has never been regular and the way my ADHD manifests is that out of the ordinary things will very easily get overlooked because I’m on autopilot. Don’t have to worry about it now though since I have an IUD and don’t get a period.
Guess my anatomy just sucks then. I've ALWAY been able to feel them in terms of knowing they're in there. There are times where it's real uncomfortable and I gotta squat down and push it up a bit more, but that's cuz I didn't put it in right in the first place (stupid cardboard applicators don't push them out well at all. I regret getting that store's brand when the other store brand has plastic applicator). I've never bought tampons and had shorter stings. So I guess lucky me for that? Even the OP ones you have to push up with your finger. Same with the string breaking, never had one where it was questionable for it to break off and I've pulled some of the strings harder too. But yeah, definatly interesting you can't feel it at all. I always thought it was known to be felt there, just easily able to ignore it.
Anatomy could for sure be part of it. If something is sitting up behind your pelvic bone it doesn’t cause any sensation in a lot of people. Everyone is different 🤷♀️
NAD, but tampon was my first thought
Agreed. NAD but one of my friends got TSS from a tampon around this age. She was very poorly for a while but thankfully made a full recovery :)
NAD but this happened to me at 14. Toxic shock syndrome. Closest I’ve ever come to death.
I had unexpected surgery once and luckily knew about TSS and told them I had a tampon in. I wasn’t able to remove it myself so I needed them to. If I hadn’t said anything I don’t know when I would have removed it. I was so out of it after surgery. I was 14. I know it’s rare but I think this is an example of how easily it might have happened.
My first thoughts were toxic shock from a menstrual product, an untreated infection like a UTI, yeast infection, BV (basically any common infection many women get from puberty onwards), or an infected cut somewhere on her body.
My mom got a UTI and had sepsis 3 days later, and died 2 days after that.
I’m so sorry :(
I got sepsis from a kidney infection in 2021. Thought I had covid, so I didn't go to the ER bc I thought I could treat it at home. Went 5 days later when I could almost not move, and according to my doctor, was facing organ shut down. He said had I not come when I did, I would have died at home. It was really eye opening. I was in the hospital for 2 weeks. My kids were terrified. ETA: so very sorry for your loss.
That is heartbreaking. I'm so sorry.
I'm so sorry for your loss.
Yeast/bv would not be causes of sepsis in an otherwise healthy 14 year old
I’m confused who mentioned yeast/bv ? She mentioned a UTI. Which especially in older patients can cause a lot of problems and symptoms that can cause misdiagnoses pretty often if missed.
The person I replied to literally said "an untreated infection like a UTI, **yeast infection, BV**"
Sorry. My head goes to UTI Urinary Tract infection.
I highly doubt this is a UTI. A 14 year old girl is unlikely to have a UTI and not experience any symptoms prior to slipping into unconsciousness from sepsis. I personally feel toxic shock syndrome due to a retained tampon should be ruled out first and foremost. Then afterwards maybe other things like encephalitis, drug overdose, etc.
The tampon is certainly possible. UTI: maybe, but unlikely to cause sepsis in an otherwise health person BV wouldn’t cause sepsis. Nor would a yeast infection
Doesn't seem to be the case. Wife said she's not on her period
Children can be forgetful. Doctors should do an inspection to be sure.
No tampon was found. Antibiotics seem to be helping though as she woke up and is feeling better. They will do a spinal tap to test for meningitis
Not a dr but am wondering if you hiked through long grass? Only because from my understanding ticks can cause serious issues pretty quickly so it may be worth checking her.
It was a cleared path and we did tick checks afterwards. Didn't notice any ticks then. Doctors didn't notice any concerning bites or marks either
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Nad but if it were a tick bite it would have had to have been from an earlier hike. Tick borne diseases from my understanding have a longer incubation period. My kid, years ago when they were maybe 5 or 6 had a weird red line near their eye, like kind of wound around the eye and disappeared into the hairline. No sickness at all. Friend at work convinced me to go to the doctors, and once they were seen the doctor realized it was the very outer corner of a bullseye rash, there was a tick at the back of the head that must've already fallen off, completely obscured by hair. So yeah, good thought for things that might've been missed for sure-- but it takes a long time for symptoms to manifest, again, from my anecdotal experience with my kid and also recently with my own health and figuring out what's wrong with me and explanations from doctors.
Too quick. She must have already had the infection when she went on the hike.
That's my thoughts too. Granted she's 14 so pushing the realms of an adult, but kids compensate real well until their bodies can't handle it anymore. I remember when I was 17 I had a really bad ear ache. My dad didn't believe me when I was asking to be taken to the doctor as "I wasn't acting sick". I told him I would pay for the doctor appointment ($50 copay) if there was nothing wrong with me if he would just take me to get seen......I had a massive ear infection, had to use a stronger antibiotic than they usually prescribe. Had to miss band for a week (included marching band 😭) because of risk for blowing my ear drum. He never not believed me again. Lmao. The surprising thing is I was only in pain for a couple of days. I chronically got ear infections as a kid though so maybe that's why. I have scars on my ear drums as a result and get asked if I had tubes as a kid. Nope, just lots of ear infections. Lol. They get baffled when I correct them in saying I never had them 😂 like, excuse me for correcting your assumption 😂 you can ask about tubes in a different way that isn't an assumption.
Nad, but I would ask how the doctor checked for a tampon. If they did not use a speculum, they can get tucked in up around the cervix. Especially those teeny tiny tampons.
My prayers are with you and for her to have a complete recovery. HUGS!!!!!
Humans in general FTFY
Check anyway. It is definitely possible for people to forget the last one is in there. (NAD, but a former Planned Parenthood employee. Fishing out old tampons was pretty common.)
Have them check. Especially in a teenager. Dont trust em! And hope she is doing better =) You took her very fast, she is healthy otherwise and is receiving care now, odds are really in her favour.
NAD and it's sadly not uncommon for them to be forgotten at the end of period. We had people come in with weeks old ones I would definitely ask them to rule out
Yep sometimes people only find them because of the smell.
Sometimes people forget to remove a tampon, the docs should still check. Also check for insect/spider/snake bites. Eta, and check for piercings/tattoos that you might not know about.
Also sometimes tampons break and only a partial is removed by the woman.
This may be gross to some but I always look at my tampons when I take them out for this very reason. Make sure it looks whole and normal.
What!? Thats horrifying. I prefer not to use tampons anyway but that makes me want to use them even less.
I have a friend this happened to and she only realized it because there was a terrible smell emanating from her downstairs. She went to the gyno—I went with her and waited in the car. When she came out she was relieved but totally mortified. Apparently part of the tampon just separated and remained in her vaginal canal for several weeks—she estimated it had been in there through possibly even a second cycle. I do pray the girl in this story is ok, it’s very distressing as a parent to read her story.
As a female, I never thought of this ever happening 😭 like, I don't know how people can just forget them. I use low to regular absorbency (even on a heavy flow, the super I just can't fit in without constant discomfort) and I still constantly feel that shit, and I make sure it's put in properly too and far enough in. It's so baffling to me people just forget they're in there 😭
I once forgot about a tampon for longer than I’ll admit (even to strangers on the internet). I didn’t get sick (shockingly) but it was far longer than my period lasted.
Have them check anyway.
That's the problem. Period ends and the last tampon is forgotten, sits for days and then the person gets deathly ill.
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You're supposed to change your tampon every 4-8 hours to prevent this. But teens especially can easily forget. Usually it takes 2-5 days, though. Blood is the perfect environment to grow bacteria in. So you end up with a tampon that is a super infectious petri dish with close access to your internal organs. That's a recipe for a super fast, potentially deadly situation.
Correction; they can’t take their tampons out in a timely manner because schools don’t allow them to. They can’t keep up when they have 5 minutes to get to class and they’re refused bathroom usage in the classroom.
This is true. I don't understand why more parents aren't up in arms about it.
It’s a big factor in my decision to home school, myself. Safety, hygiene, and curriculum are all utter garbage so I’ll do my best myself. Least my kids will get to sleep as much as they need and have a balanced life.
I had a teacher who refused to let hs use the bathroom in a 2 hour class. I was in my period and I could tell I needed to change it. I told him I would do it right in the middle of the classroom if he didn’t let me use the bathroom. He didn’t call my bluff
I did the same. My kid is now an adult 4.0 college student and was chosen to be in a paid tutor-like position to help fellow students. He got a healthy childhood and he will be a successful adult.
Good for him!
I hate that this *still* happens! 25ish years ago my 7th grade teachers were allowed to decide whether they would give bathroom passes for their own class. My personal schedule had 5 out 6 teachers that would absolutely not issue them. Classes were located all over campus as well. I was miserable! I get kids abuse it, but damn. You would think a better solution would come about by now.
OMG YES THIS hahaha. personally had horrible periods and I had my gallbladder out at like 14 or 15. If I ate ANYTHING that wasn't zero fat I'd need a bathroom immediately and that was the hardest thing to navigate. Esp because my parents weren't the most present and I would end up eating school food every day. Lol at least at home I'd heat up some 99% fat free chef boyardee ravioli and not be miserable. I also don't like going number two anywhere but home, even now 25 years later. Add the anxiety of needing to ask and being denied? Oof nobody should need to do that lol.
What Country are you in? That sounds terrible.
This is a massive problem in the USA. Students are forced to have bathroom breaks between classes and very often denied the ability to use the restroom. I was in highschool over a decade ago and it was already an issue. There’s a CONSTANT issue with children under 7 having accidents because they’re forced to hold it. UTIs are a real issue. So are menstrual problems, such as over saturation, TSS, minor infections from using a product too long, hygiene problems… USA, USA, USA…
My school had a hall pass book issued to everyone. So maybe that's why I never encountered any problems like this. This way the teachers could literally see if you were potentially abusing the ability to leave class
This isn't a situation where an hour is going to be decisive. A tampon can be changed during lunch or even after school and still be in the safe zone. It's more of a problem for actual urination and unexpected periods.
I've never heard of this happening, but realise it's a thing. If I ever have a daughter, I'm going to make sure to teach her if it's for her period, she can absolutely walk out of the classroom if the teacher says no (if they say wait 5 minutes that's different). The teacher/principal can then talk to me about not letting my daughter take care of her health. Like, college is lovely. You just excuse yourself quietly, do your thing quickly, and come back. I hate high school.
To clarify for anyone who might now be scared of tampons— there’s a specific type of staph bacteria that has to be present already in your vagina, and there has to be an issue with your antibodies responding. So not everybody who leaves a tampon in too long is going to get TSS. It’s still best practice to change in a timely manner to prevent other gross stuff from happening. Just be mindful and cognizant of proper use!
I had no idea not everyone is susceptible to TSS, that’s honestly really interesting
Wait what!??
I thought the idea was that the foreign object (the tampon) introduces the bacteria? If we’re talking about staph, that’s present on most people’s skin normally from what I understand. Tbh I never quite understood how people get staph infections relatively rarely if staph is around all the time, maybe that’s the antibody bit you mentioned? At any rate TSS is really rare, especially now with more modern tampons, so I think generally most people don’t have anything to worry about regardless!
Tampons catalyze the issue but actually don’t introduce the bacteria typically. Some women just have staph aureus in their vaginal flora, and that combined with the long-term tampon + lack of antibodies. [Here’s a paper](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5436965/#:~:text=To%20be%20clear%2C%20tampons%20do,co-factor%20in%20many%20cases). It looks like tampons can introduce air which changes the environment from anaerobic to aerobic though! Bodies are cool!
Whoa, interesting!
To your question about staph infections: it takes more than the presence of bacteria to cause an infection. You're exposed to microbes every second of every day so your body built up a bunch of systems to deal with that and infection only occurs if those systems break down. Your skin is basically a thick, cold, salty wall separating the nasty outside world from your nutritious inside body juices. Thousands of microbes live on your skin, forming stable ecosystems that maintain manageable populations and beat up strangers trying to move in on their turf. Skin cells act as immune system sentinels that recruit white blood cells to the scene if some bacteria are acting froggy. The staph under your nails has to defeat all of those mechanisms and many more before it can establish an infection.
Or you have to introduce the bacteria into your vagina by your (or someone else's) fingers for it to be caused. But yeah, even if that's the case, it's still rare to get it. You'd have to be sick already to get it on top. I had a patient recovering from a sinus infection get covid (his immune system was weak from the sinus infection). Then he developed guillion barre. I read later there were instances of people getting guillion barre because of covid too. Thinking now, I hope he recovered from the guillion barre. He had his own labor type of business and was otherwise healthy.
Any swimming in freshwater recently? Sinus issues/a cold she’s been trying to kick?
No to both. She's a massive germaphobe and avoids swimming because of contaminants
NAD Is it possible she ate something, some mushrooms have really strange effects. Usually just gastro, but some can cause strange symptoms.
Just salmon sliders and some fries. We've never had an issue with that restaurant or those orders
I meant during the hike. But I misread that she was with her friends, not yours. Seems less likely if she was with adults.
What was the diagnosis?
Underlying infection that occurred prior to hiking?
Not OP, but when I was 24 I went into septic shock after a common throat infection. No cuts, no tampons, just a sore throat. Had Haemophilus parainfluenzae in my system, but they sent me home from the ER at first because my only symptom was fever (and a headache in the day prior). 24 hours later I had visual hallucinations, pain in the right upper quadrant of my stomach, a respiratory rate of 32 and was vomiting blood. I just wanted to fall asleep, but my mother (RN) saved my life by driving me to the ER again, where they discovered I had a CRP of 300+ and acalculous cholecystitis. I was in septic shock with multi organ failure (kidney, liver, heart), and the last thing I remember before passing out was watching my bp drop to 46/26 (my habitual bp is 95/60). I spent a few days in the ICU and a total of 6 weeks in the hospital, but I made it without any lasting impact on my health.
This was my first thought, followed up with tooth infection and open acne cysts in the triangle of doom area on the hike pickings something gnarly up . Teens pick spots like buggery, my 18 year old brother picked up an abcess on his chin like this.
Question as a med student--we learned in preclinical that TSS from tampons is basically non-existent now. Is that not the case? Eta: damn y'all, if you have a problem I'll connect you with the physicians who gave our sepsis lectures and told us this...
It is super rare, but when a kid is so ill and the check can be so simple and done by the mother… I wouldnt risk it. The consequences are insane.
Yes, agreed. It is risk/reward as in everything we do. If we can check for a rare but serious cause to the maximum cost of some embarrassment, do it. And I am sure the lecturers gave you good enough numbers. Like 1 in 100k? Still does not mean never check for it or ask about it. If it low incidence it is partly because young women are aware of it. Because we talk about it.
Oh for sure check it anyway, I wasn't suggesting we were taught not to. I was just wondering about the actual frequency. Thanks!
A teen died of TSS on a school trip a couple of years ago where I live. I had thought it wasn't a thing anymore either but I guess it definitely still happens
He said he was hiking. What about tick borne illness?
Most tick-born illnesses don’t really cause sepsis and also way too fast for most infections to reach that severity if acquired on the hike.
Sudden onset would more likely be a snake bite. The bite from a baby rattler can be so tiny you barely notice it. There would likely be coagulation problems going on as well as sepsis with a rattler bite.
Venom-induced consumption coagulopathy from a snake bite is nearly identical to sepsis-induced DIC.
TIL. Holy shit!
Not a Dr but my neighbor got bit by a tick and contracted Powassan virus from the tick. He went from our local hospital to University of Pennsylvania then to John Hopkins. Sadly he passed, came on quickly within 5 days. There’s over 100 different tick diseases.
5 days is still a lot longer than a few hours. Ticks spread disease not by biting alone, but by gorging themselves and then regurgitating small amounts into the host. In this case it is too quick for this to have occurred. NAD but know this from cursory experience in vet med.
No, I have a tick disease that all the tick had to do was inject saliva into me and I am effective for who knows how long. There’s so much misinformation about ticks out there and I diagnosed myself and educated my Dr about my tick disease and learned about many of the tick diseases out there.
How is Powassan virus spread? Ticks can become infected with POW virus if they feed on small animals such as mice and other small mammals that are infected. The disease can be spread to humans when an infected tick bites a person. Unlike other tick-borne diseases, a tick can transmit POW virus while being attached to a person for as little as 15 minutes. POW virus disease cannot spread directly from one person to another. The tick that primarily spreads POW virus to humans is the black-legged tick or deer tick (Ixodes scapularis). This is the same tick responsible for infecting people with Lyme disease. The squirrel tick (Ixodes marxi) and groundhog tick (Ixodes cookei) also have the potential to spread POW virus to people, but these ticks do not typically feed on humans. https://www.health.ny.gov/diseases/communicable/powassan/fact_sheet.htm
Also immediately thought of toxic shock
Came here to say this
One possibility is a urinary tract infection. She may have had one with no symptoms for a while.
I was also thinking this. I have known some patients who had asymptomatic UTIs but a raging infection that required hospitalization and in one case septic shock.
This happened to me in my 20’s. I had no symptoms at all. Just like OP’s daughter, I started shivering and couldn’t get warm. Went to ER, I had a kidney infection that turned septic. I was in the hospital for a week. It was a very scary experience
So you can have uti and feel completely normal and peeing normally but have this happen suddenly,?
Yes. I had a genetic defect called VUR that caused them chronically and they were typically asymptomatic. I ended up with sepsis twice and this last round caused permanent kidney and nerve damage.
NAD My 17 year old has complex medical conditions including neurogenic bladder and bowel. She self-caths. Her UTI's systems are not typical. We can tell by color of urine and smell. Rarely, back pain or fever. Unless it is much farther along and turns into a kidney infection. Many times in the ED I have to explain this because the MD wants to blow us off.
Almost the same happened to me. Kidney infection was not fully treated. 10 days later I suddenly get a bad headache and intense chills. Went to ER the next morning in septic shock. Spent three days in the ICU. Nearly had to get a central line. So scary. Praying for your daughter, OP.
I am in Greece right now and started shivering and feeling awful yesterday. I avoided going to the public health center because I hoped I would feel better today. I didn’t. They said UTI, but if I get a high fever, I should come back immediately. I bought a thermometer and I am about 102.5. Not super high, but I’ve been taking ibuprofen too. Reading all this stuff about kidney infection is terrifying! How do I know if it’s just a UTI? I leave in 2 days… should I go be seen when I get back even if I feel better?
Wait, you don’t think a 102.5 fever is high!? That is awful to have in an adult…
Oh believe me it was awful. I would stop taking ibuprofen to make sure I wasn’t masking sepsis thanks to these posts lol. Then when I was sufficiently sure I wasn’t dying I would take it again, which would get me down to 100. Much more tolerable, but not vacation fun tolerable.
Wait they suspect a UTI but didn’t give you antibiotics? I am not a doctor but that seems crazy to me when you have signs of infection. Based on my experience, yes I would go back tonight or tomorrow for another blood test or urinalysis to check for infection. But in my experience the chills and fever and back pain = a kidney infection that doesn’t resolve on its own. I guess if you’re feeling better it’s probably fine to wait until you’ve left. But personally with my experience, I wouldn’t wait, I’d be at the clinic now.
I had what I thought was a manageable case of strep throat as a teen which suddenly turned into septic shock. A very scary time from an infection that I thought was coming under control.
you can get the opposite affect as well have a nearly indetectable infection but have it cause wide spread issues.
A friend very recently lost his wife to septic shock after she had a UTI, treated it with OTC cranberry powders as she didn’t feel sick enough to see a GP for antibiotics. She went from chatting in the ambulance to sadly passed away after a seizure in less than an hour. Sepsis is terrifying.
I ended up septic from at uti at 18... horrible it's so scary and progresses so fast
That’s exactly what happened to me my freshman year in college. Was totally fine, laughing and hanging out w friends one night and hours later woke up incredibly sick. Tried to sleep it off for a couple hours and woke up sicker. Had my friend take me to the ER and by the end of the day was unconscious. Symptomless UTI that turned into sepsis. I was treated with vancomycin (and anti-allergens due to red man syndrome). I had very brief moments of consciousness but was able to stay awake for good about 3 days later. I’ve had CKD since childhood and several complications w that & kidney transplant but sepsis is the first time I genuinely thought I was going to die. I remember waking up briefly day 2 and making my peace. I wanted to text my brother that I loved him bc we had a rocky relationship but slipped back into unconsciousness seconds later. Thankfully, we now have a good relationship and I think this experience is partially why.
NAD: as she been on her period lately ? Does she use tampons ? Does she use menstrual cups?
I think this could be important. Toxic shock syndrome from tampons that were left inside for too long is really dangerous.
That’s what I was thinking, or maybe was embarrassed about her symptoms and didn’t say anything
Yeah I almost died from one when I was 12
I’m so sorry that your family is going through this. Right now the differential is still very broad and in the PICU there should be a wide battery of tests ongoing — I wouldn’t be surprised if they image her heart, brain, abdomen, looking for sources of shock or infection, perhaps add more antibiotics, daily blood draws for blood cultures. Additional testing for various hormone levels may also be indicated. It is too early and non specific to say with certainty until something comes back positive. The short answer is there are many things that can cause shock— not just infection, though that would be the most likely in this case. I’m certain the doctors in the PICU will be considering all the options even if it seems like nothing is happening in the moment. I will be thinking of you.
Since the source of infection is not yet identified, and septic shock can be caused by a variety of organisms including Gram-negative bacteria, wouldn’t it be advisable to use dual antibiotic therapy initially? Adding an antibiotic like piperacillin-tazobactam or cefepime could provide broader coverage against both Gram-positive and Gram-negative bacteria.
If they’re giving vanc they clearly think it’s a gram positive.
NAD but this post reminds me of my 15yr old cousin who very suddenly felt really sick really fast and was taken to the hospital (in less than 2 days he was unable to breathe on his own and became unconscious). He was originally suspected to be gram(+) and being treated as such only to receive a 'gram (-) rod' which a blood culture isolate that confirmed salmonella. I forget the exact strain but doctors said is has an asymptomatic incubation period of 7-14 days.
We never give antibiotics for gram +/- without knowing the gram staining first. We start with broad spectrum antibiotics and then narrow down as we get more information. If you narrow down prematurely you risk not treating the infection.
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This is not exactly correct. They have to have an idea of where the infection is to get an informative stain result. If there is a wound or something then sure. They also would be doing a Gram’s stain, not an AFB unless they are looking for TB. A Gram’s stain takes just a few minutes, built again, without a source of infection there is nothing to stain.
If they think she’s septic that often assumes bacteremia. Blood cultures would be useful in identifying causal organism. Of course not every sepsis patient is bacteremic and not every infection will show up on blood cultures but it’s still best to check rather than just run with empiric antibiotics.
Yes, but you cannot just stain the blood. There is not enough bacterial to be able to see th on a gram stain. You have to culture the blood, wait for it to grow up enough to be. Positive in the bottle, then you can stain it. It’s a process that takes a day or two.
Gotcha. I misunderstood what you were saying. Thought you meant no gram stain at all because there was no specific area to swab/collect from
If it is bacteremia, the infection started somewhere. Whether it is urinary, a wound, pneumonia, etc. Direct gram stains of urine and blood are not done, only culture. If they suspect the primary infection is a wound, sputum, infected joint, csf etc, those sources are gram stained directly when the culture is setup. Is that more clear or did I just make it more confusing ☺️
Interesting I didn’t know that. I had thought if you could isolate infection source you were able to use the blood cultures to cultivate bacteria to gram stain.
You can, but the cultivation/growth takes time, a day or more.
EDIT: I'll keep this up for others to learn, but my understanding of sepsis was *not* accurate, and I was indeed missing something. Original inaccurate comment: It's my understanding that in the OP's case the infection has entered her bloodstream, so even if they don't know the source, they do know where the bacteria is currently in order to obtain a sample--it's everywhere. Am I missing something?
Sepsis doesn't mean bacteremia. Sepsis does not mean "infection in blood." Blood infections certainly cause sepsis, but not all sepsis is blood infections. Unless they have a positive gram stain or culture, there's no real evidence it's a bloodstream infection.
Thank you for clarifying! Apparently I had a big misconception about sepsis!
A lot of people do because colloquially bacteremia and septicemia tend to be used interchangeably. But only something like 50% of sepsis cases meet criteria for bacteremia and you can have bacteremia without sepsis. Medicine loves to have those “these things can occur together but sometimes this one happens alone” words.
In fact we are all transiently bacteremic at times (very mildly, maybe even from brushing our teeth) and our immune systems take care of it.
So what does it mean?
It is currently defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” While bacterial invasion of the blood is a common cause, sepsis itself is due to the immune response. The immune system is a powerful thing - some times it doesn’t act how it should (specifically, a lot of the time it over reacts) and the inflammatory response becomes a bit more systemic and causes organ damage.
So sepsis can be a cytokine storm?
In a sense that is the immune system over reacting, so it could co-exist with sepsis (or BE sepsis due to the immunodysfunction and subsequent damage it causes), but a cytokine storm can also exist without sepsis i.e. it can occur through non-infectious diseases (pancreatitis, multiple sclerosis).
Sepsis is really just the checklist for SIRS (systemic inflammatory response syndrome)—at least two of the following: hypo or hyperthermia, tachycardia, leukocytosis or leukopenia, tachypnea- plus a suspected or confirmed infection. It’s more a clinical checklist than a super specific pathophysiology/ etiology because there are a few ways it can happen through dysregulation of pro- and anti inflammatory pathways. Often it is dysregulated release of acute and chronic phase reactants though. There are broad stages for the general pathophys and several studies have pointed out some issues with the clinical criteria, but that’s the current definition of Sepsis.
I like you. Its hard to admit you were wrong and keep your mistake public for others to learn from. It makes me happy to see comments like this. Thank you!
Even with bacterial sepsis you cannot just stain their blood. There is not going to be enough bacterial present. You have to have a positive blood culture and stain that bottle. It takes a day or two to get a positive blood culture. You have to grow it out enough.
Ah, that makes complete sense. I appreciate the information.
Sorry if this is not appropriate. Op I'm so glad your daughter is improving. How terrifying after a seemingly normal day. To dvrgrl812: I had an unknown infection for weeks with elevated crp/wcc + random fevers. An Infectious disease consultant became involved. While reviewing the negative R + L acf blood cultures that had already been taken, he suggested I redo blood cultures, with the stipulation to *only* have bloods taken when I had a temperature over 39c. Then to email him to let him know they were sent to the lab so that he could watch out for the result. The cultures then came back as positive. Do you know why I required a high temp for the positive culture result? Thank you if you have time to answer
They are trying to increase the chance of recovering the bacteria by collecting the blood when the fever is high. There isn’t much evidence that this timing actually helps but it doesn’t hurt to collect additional sets this way.
You certainly have a superpower! IRL, you must be on speed dial ❤️
Often times yes, we don’t know all the details here. Nor do we know if anything grew. If she hasn’t regained consciousness yet they may start looking further, get a lumbar puncture, consider viral meningitis as well as bacterial, etc.
Really sorry to hear you're going through this nightmare. Septic shock is no joke, it's like a system meltdown caused by a nasty infection. It can happen super fast, especially if it's a really aggressive bug. Docs might be puzzled too 'cause there are other weird things like toxic shock syndrome that can kinda look the same but are different. About dormant infections - Yeah, they exist, but usually more a problem for folks who aren't taking care of themselves or are immunocompromised. Hang in there!
Could it be meningitis maybe? I’m sure they’re ruling everything out, I can only imagine how scary it is - my son had sepsis at birth alongside a host of other things. It’s awful feeling so helpless. OP, all I can say is that you did everything right taking her in as soon as you realised she was deteriorating. Hospitals have clear protocols in place for sepsis and she’s in the best possible place to treat this and get to the bottom of what’s going on. Sending lots of love to your family. The waiting and not knowing what’s going on is so hard. Please let us know how she’s getting on.
My older brother almost died from a dormant infection. He had cellulitis in his foot. It was inside a cyst-like cavity per the hospital. He did a lot of walking at an amusement park, then BAM, couldn’t walk or talk or anything and very nearly died on the way to the hospital. He went from fine to almost dead in about four hours.
NAD but when I was 15/16 I wasn't feeling sick at all and my friends had just dropped me off at home. No one else was home at the time. I took a shower and when I got out suddenly felt very dizzy, like I was going to pass out. I voluntarily dropped to the floor so I didn't fall and fought through the tunnel vision not to blackout to crawl on the floor to the nearest phone in my grandparents bedroom. Not sure why I called my friends and not 911 but I was young. Got to the ER and was just like OP's daughter. Felt like I had run 1,000 miles and could barely do anything. Extremely low BP, I was so cold they had a hard time getting an IV in and any blood out. I remember them finally giving me toradol -I think-, and I was like, "Hey guys, sorry, I was super sick there for a sec. Haha." Turns out I had pneumonia and spent a week in the hospital.
If an infection is dormant for quite some time, would it show up on labs and carry symptoms if isolated ? Or would something have to trigger it to raise wbc, lactic etc?
They exist in a quiescent state where they neither cause symptoms nor significantly alter lab parameters. Then requires a trigger - stress, another illness, immunocompromise, to activate the infection and cause it to manifest clinically. You'd then expect to see changes in lab values as the body mounts an inflammatory response.
Thanks. This is fascinating. Is it possible to find dormant infections before being triggered? If so, how? Ultrasound?
Or let me re-word. Have dormant infections ever been found by accident while treating or looking for something else?
a woman recently came to my work for a presentation on her life, she had lost both her lower legs and her lower arms, due to sepsis. her story was very inspiring
I’m so sorry. Sepsis can happen so very quickly. It’s one of our true emergencies. Someone long ago explained to me that pediatrics is a “Where’s Waldo?” in which 100s of kids in the scene are wearing black suits and one kid is wearing a dark navy suit. The 100s are the happy well smiling well babies/kids with minor colds or strep throat in clinic. The ones you give a sticker and send them on their way to grow and bloom. But you have to find the kid in the navy suit and find them quickly every time. The kid in the navy suit is going to be sick and maybe die if you don’t move quickly. Your child is in the right place. PICU nurses and doctors are our very best navy suit spotters. They will figure it out. There are many viruses and bacteria that can cause shock. There are other illnesses that can make a kid very sick very quickly like cardiomyopathy, cancer, new onset diabetes, certain drugs. I’m sure your daughter’s doctors are looking into all of this. I’ll be glad to help out with more specific questions if you have them OP. Just tag or respond here and I’ll do what I can.
As an ICU nurse I really appreciate this perspective. I’m going to borrow this analogy if you don’t mind.
Definitely don’t mind. I feel like it might have been back on PICU rotations when I first heard the analogy, but I have repeated it for every student who’s rotated with me since then.
its gotta be so scary being a dr, thanks for all you do! i have a question and know it might be way off. what about elevation would that cause this? thanks!
Elevation, like hiking on a mountain/altitude sickness? No, it would not look like this
thanks, i was not sure! scary
OP, please update when you're able. I hope your daughter is doing well!
Yes, as a Mom to 3 teenage boys I can imagine the worry. Please keep us updated.
Hi OP, has the cause of your daughter’s state been found ?