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June 12, 1987

Toxic Shock Syndrome, Staphylococcus aureus, and Influenza

JAMA. 1987;257(22):3070-3071. doi:10.1001/jama.1987.03390220068019

To the Editor.—  The recent reports of toxic shock syndrome (TSS) during influenza outbreaks1,2 may not imply a unique association with the influenza virus, but are more probably due to secondary focal staphylococcal infections including sinusitis—a frequent complication of influenza. The patient reported by Sperber and Francis1 had clear-cut pneumonia, as did two of the nine patients reported by MacDonald et al2; the remainder could have had occult sinus infection. In either situation, it would not be unusual to culture Staphylococcus aureus from respiratory secretions. Such focal infections appear to be linked both epidemiologically and microbiologically to the pathogenesis of TSS.3 During the last two influenza outbreaks in Denver, we have noted a large number of patients with secondary sinusitis. Growth of a toxin producing S aureus in a sinus (or in a lung) may provide conditions for toxin production that may not ordinarily be present