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A Newly Recognized Complication of Influenza and Influenzalike Illness

Kristine L. MacDonald, MD; Michael T. Osterholm, PhD, MPH; Craig W. Hedberg, MS; Christian G. Schrock, MD; Garry F. Peterson, MD, JD; Jeffrey M. Jentzen, MD; Stanley A. Leonard, MD; Patrick M. Schlievert, PhD

JAMA. 1987;257(8):1053-1058.

Abstract
Nine cases of severe hypotension or death compatible with toxic shock syndrome (TSS) as a complication of influenza and influenzalike illness were identified in Minnesota with onsets between Jan 2,1986, and Feb 23,1986, in which five of the patients died. During this time, an influenza outbreak was occurring in the state. Cultures of respiratory secretions were performed in eight patients; Staphylococcus aureus was isolated from all of them. Seven S aureus isolates were available for determination of exotoxin production; five isolates produced toxic shock syndrome toxin-1, one produced enterotoxin B, and one produced both. Acute influenza B infection was confirmed in three of four patients for whom throat cultures or acute and convalescent serum samples were available. Two patients fulfilled the Centers for Disease Control—confirmed case definition for TSS. Four additional patients fulfilled the CDC criteria for a probable case of TSS, and TSS was a likely diagnosis in the remaining three patients. The initial presentation was suggestive of nonsuppurative tracheitis or viral pneumonia in eight patients. In the remaining patient, the initial clinical presentation was compatible with staphylococcal pneumonia. This report demonstrates that TSS can occur as a complication of influenza and influenzalike illness.

(JAMA 1987;257:1053-1058)

Author Affiliations
From the Acute Disease Epidemiology Section, Minnesota Department of Health, Minneapolis (Dr Osterholm and Mr Hedberg); the Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis (Dr Osterholm); North Memorial Medical Center, Robbinsdale, Minn (Dr Schrock); Hennepin County Medical Examiner's Office, Minneapolis (Drs Peterson and Jentzen); the Departments of Pediatrics (Dr Leonard) and Microbiology (Dr Schlievert), University of Minnesota Medical School, Minneapolis; St Paul Children's Hospital (Dr Leonard); and the Division of Field Services, Epidemiology Program Office, Centers for Disease Control, Atlanta (Dr MacDonald).

Footnotes
Reprint requests to the Acute Disease Epidemiology Section, Minnesota Department of Health, 717 Delaware St SE, PO Box 9441, Minneapolis, MN 55440 (Dr MacDonald).

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