The toxic shock syndrome is often associated with Staphylococcus aureus and is mediated by toxic shock syndrome toxin-1 (TSST-1) and other enterotoxins. We describe the first case of the toxic shock syndrome associated with a coagulase-negative staphylococcal species, S. lugdunensis.

A 33-year-old, otherwise healthy woman developed nausea, vomiting, diffuse abdominal pain, myalgias, and confusion within 48 hours of tooth extraction and Gelfoam packing (Pharmacia-Upjohn, Kalamazoo, Michigan). Evaluation in the emergency department revealed a faint erythematous macular rash of the chest and livedo reticularis of the legs. General and pelvic examination were otherwise normal. Admission data (Table 1) fulfilled the criteria for the toxic shock syndrome. Cultures of blood and purulant right maxillary sinus aspirate showed coagulase-negative staphylococcal species, and the species of the blood isolates was identified S. lugdunensis. Tests for coagulase, TSST-1, staphylococcal enterotoxins A to E, and exfoliatin toxin A were negative. No S. aureus or S. pyogenes were isolated from blood, urine, sputum, or sinus or vaginal secretions. The patient improved with medical treatment. Desquamation of the palms and soles was noted before discharge.

Staphylococcus lugdunensis has been associated with other severe infections, including prosthetic and native valve endocarditis, peritonitis, infective arthritis, vascular prosthesis infection, osteomyelitis, brain abscess, bacteremia, septicemia, and septic shock. Previous reports implicated coagulase-negative staphylococcal species in the pathogenesis of the toxic shock syndrome [1, 2] and suggested TSST-1 production [1, 2], although subsequent analysis of select coagulase-negative staphylococcal species isolates failed to demonstrate TSST-1 or a TSST-1 gene [3].

This case expands the spectrum of severe infections associated with S. lugdunensis. Reports of S. lugdunensis endocarditis after tooth extraction [4] and the toxic shock syndrome associated with Gelfoam nasal packing [5] suggest a portal of entry in this case. The absence of a toxic shock syndrome-associated enterotoxin does not exclude the possibility of a novel virulence factor. As gram-positive organisms are increasingly identified in the bacteremic sepsis syndrome, the possibility that subspecies of coagulase-negative staphylococcal species may have different virulence patterns should be recognized.