Staphylococcal toxic shock syndrome with pre-exposure to Cox-2 inhibitor: symptom masking and delayed treatment

Due to uncommon occurrence of staphylococcal toxic shock syndrome (TSS) in male patient, streptococcal origin is often suspected and treated as such. Pre-exposure to nonsteroidal anti-inflammatory drugs had been associated with masking of inflammatory symptoms. These two factors may lead to delay in receiving appropriate antibiotic treatment. We present a case of staphylococcal toxic shock in a diabetic male. He was initially presented to emergency department with abdominal pain, leg swelling and shortness of breath. The patient was having minor skin ulcerations twelve days before admission. He was prescribed with etoricoxib for his shoulder pain for 3 days prior to admission. Initial presentations upon admission showed upper gastrointestinal bleeding, metabolic acidosis and acute kidney injury. He developed TSS with multiorgan failure one day later. Initial diagnosis was streptococcal TSS and therefore intravenous immunoglobulin and clindamycin was initiated. Nevertheless, repeated culture from blood and wound showed staphylococcal infection. The diagnosis was changed to staphylococcal TSS and intravenous cloxacillin was initiated. However, the patient succumbed to the illness after 11 days of admission. In this case report, pre-exposure to etoricoxib may cause masking of inflammatory symptoms and rapid progression of a wound infection into TSS. Rarity of staphylococcal TSS in male and difficulties in differentiating between streptococcal and staphylococcal TSS led to delay in appropriate treatment.