A young man with rash and respiratory distress.

A 27-year-old man presented with high fever and septic shock. On examination, there was diffuse blanchable erythematous macular rash on his trunk and extremities (Figure 1A–C). He was intubated due to extreme respiratory distress. Fiberoptic bronchoscopy showed diffuse mucosal sloughing and hemorrhage at the proximal airways (Figure 2A,B). Respiratory specimens yielded methicillin-susceptible Staphylococcus aureus, influenza A (H1) RNA and human coronavirus OC43 RNA. He was treated with intravenous immunoglobulin, clindamycin, and meropenem, together with oseltamivir for treatment of influenza A. Screening for human immunodeficiency virus was negative. Computed tomography of the thorax did not show evidence of necrotizing pneumonia. With supportive therapy, he was extubated and discharged from the ICU. Upon review one week after the initial presentation, there was desquamation over the trunk and limbs (Figure 3A,B), a characteristic feature of staphylococcal toxic shock syndrome.1 Severe cases of staphylococcal infection resulting in necrotizing tracheobronchitis rarely have been described.2, 3 The presence of macular rash with septic shock on presentation should alert clinicians of the possibility of staphylococcal infection with toxic shock syndrome. These images underscore the criticality of promptly recognizing the characteristic skin rash, providing appropriate treatment accordingly, and looking out for the potential complication of necrotizing tracheobronchitis. The patient provided consent for publication of the images.