Biochemical Investigation Is no Substitute

Kathryn LA Rogers, Ravindra S Date, Jeremy B Ward
Department of Gastrointestinal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust.
Chorley, Lancashire, United Kingdom
ABSTRACT
Context Toxic shock syndrome has been
shown previously to be associated with
hyperamylasaemia. However, serum amylase
levels do not usually exceed three times upper
limit of normal in these cases.
Case report We report a case of a young girl
of 17 years who presented with upper
abdominal pain, severe shock and raised
serum amylase level of 3,898 U/L, giving an
impression of severe acute pancreatitis. It was
only after finding a tampon in her vagina, and
subsequently growing Staphylococcus aureus
in her blood cultures, did the diagnosis of
toxic shock syndrome become apparent. She
recovered fully with supportive treatment and
appropriate antibiotics.
Conclusions Toxic shock syndrome with
such a high level of serum amylase has not
been previously reported. This case
exemplifies the importance of repeated
clinical evaluation of patients in this era of
multiple investigations, and not simply
relying on biochemical values for diagnosis.
INTRODUCTION
The recent review of Atlanta classification
recommends that the diagnosis of acute
pancreatitis should incorporate two of the
following three criteria: upper abdominal
pain, amylase and/or lipase levels at least
three times the upper limit of normal, and CT
or MRI findings compatible with acute
pancreatitis [1].
Hyperamylasaemia can also be associated
with other conditions such as parotitis,
peritonitis, ectopic pregnancy, severe sepsis
and acidosis [2]However serum amylase
levels rarely exceed three times upper limit of
normal in these conditions.
Toxic shock syndrome, secondary to
Staphylococcus infection, is well recognised
in young girls following the use of tampons,
and can be associated with hyper-
amylasaemia.
We report a case of a young girl who
presented with upper abdominal pain and very
high serum amylase levels combined with
systemic shock causing a diagnostic dilemma.
CASE REPORT
A young girl of 17 was admitted to the
medical assessment unit with sudden onset of
diarrhoea and vomiting over the previous 12
hours. She also complained of upper
abdominal and back pain. She was known to
be sexually active and was currently
menstruating. She denied drinking alcohol.
On examination she was cold and clammy.
Her pulse was 119 beats/min, temperature
38.5°C and blood pressure was 124/42
mmHg. Abdominal examination revealed
minimal tenderness in right upper quadrant
but was otherwise unremarkable. At the time
of catheterisation she was found to have a
retained tampon, which was removed, and
vaginal swabs were sent for culture.
Her blood investigations showed severe
metabolic acidosis, hemoglobin 15.1 g/dL
(reference range: 11.5-16.5 g/dL), white
blood cells 17.2 x10
9
/L (reference range: 4-11

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210
x10
9
/L), urea 8.4 mmol/L (reference range:
1.7-8.3 mmol/L), creatinine 339 µmol/L
(reference range: 44-80 µmol/L) and serum
amylase 833 U/L (reference range: 28-100
U/L). Her urine examination was entirely
normal. She was referred to surgeons with the
working diagnosis of acute pancreatitis. An
urgent CT scan was requested which showed
some retroperitoneal oedema but a completely
normal pancreas (Figure 1). Urology consult
was made to rule out renal sepsis. She was
also examined by the gynaecologists who
thought that the diagnosis of toxic shock was
unlikely. She was commenced on broad-
spectrum intravenous antibiotics. Over the
next 24 hours her condition deteriorated, and
she developed multi-organ failure (MOF)
requiring ventilatory and ionotropic support
along with haemofiltration. Serum amylase
levels reached 3,898 U/L. Rest of the relevant
daily investigations are tabulated in Table 1.
Two days later she had an ultrasound scan
which showed a normal pancreas and no
gallstones in the gallbladder. In the interim
her blood cultures grew Staphylococcus
aureus, as did the vaginal swabs supporting
the diagnosis of toxic shock. Her stool
cultures also grew Shigella and so appropriate
alterations to the antibiotics were made. Over
next few days her general condition improved
and serum amylase levels returned to normal.
The patient made a full recovery and was
discharged home 8 days later.
DISCUSSION
Toxic shock syndrome is a clinical condition
most commonly caused by either
Staphylococcus aureus or Streptococcus
pyogenes. Hyperamylasaemia in toxic shock
is due to acinar cell damage, secondary to
either overwhelming sepsis or the toxins
produced by the organisms.
In this case it is not clear why serum amylase
levels reached such high levels that are not
normally associated with toxic shock
syndrome. Possible mechanisms, which could
have contributed to extreme hyper-
amylasaemia in our patient, are renal failure,
impairing the clearance of amylase, and
Shigella infection. Though there is no
reported association between the Shigella
infection and pancreatitis, acute pancreatitis
secondary to Campylobacter jejuni infection
has been reported, particularly in the presence
of genetic mutations [3]. We suspect that
some element of acute interstitial pancreatitis
itself could have contributed to hyper-
amylasaemia. However, it is unlikely that
severe acute pancreatitis complicated by
three-organ-failure would respond so
dramatically to antibiotics and recover so
quickly.
In this case the peak serum amylase level of
3,898 U/L led us to believe in the diagnosis of
pancreatitis, even though the overall clinical
presentation was not entirely in keeping with
this. Review of the clinical situation and the
quest for logical explanation of patient’s
clinical condition led us to the diagnosis of
toxic shock syndrome secondary to a retained
tampon.
Toxic shock syndrome can mimic several
common diseases [4] and so can be difficult
to diagnose. The incidence of toxic shock
syndrome is increasing [5, 6] and a high index
of suspicion is necessary for the diagnosis,
Figure 1. CT scan showing normal pancreas.
Table 1. Biochemical changes during hospital stay.
Day of admission Serum
amylase
(U/L)
CRP
(mg/L)
Albumin
(g/L)
1
833
93
41
2
3,898
-
26
3
1,037
240
25
4
341
228
25
5
234
153
22
9
130
17
31
Reference range
28-100
0-5
35-55

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JOP. J Pancreas (Online) 2008; 9(2):209-211.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 2 - March 2008. [ISSN 1590-8577]
211
especially as the presentation may not be
classical [7].
In conclusion, we suggest that even such high
level of serum amylase may not always be
diagnostic of pancreatitis, especially when an
obvious cause is not demonstrated. The
management of the patients should be guided
by repeated evaluation of clinical situation
and not merely by conventional interpretation
of biochemistry results.
Received November 28
th
, 2007 - Accepted
December 14
th
, 2007
Keywords Amylases; Pancreatitis; Shock,
Septic
Conflict of interest The authors have no
potential conflicts of interest
Correspondence
Ravindra S Date
Department of Gastrointestinal Surgery
Lancashire Teaching Hospital NHS
Foundation Trust
Preston Road
Chorley
Lancashire, PR7 1PP
United Kingdom
Phone: +44-01257.245.267
Fax: +44-01257.245.495
E-mail: ravidate@hotmail.com
Document URL: http://www.joplink.net/prev/200803/05.html
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