Extreme lymphocytopenia associated with toxic shock syndrome

We report an unusual case of extreme lymphocytopenia associated with staphylococcal toxic shock syndrome. A young, sexually promiscuous man presented with high fevers, productive cough, nausea with occasional vomiting, mild headache and right midthoracic and shoulder pain. His initial lymphocyte count was 72. Such a presentation in an inner city hospital, where about 15% of admissions are AIDS-related, put the diagnosis of AIDS high on the differential list. However, the CD4:CD8 ratio was 1.7, which was inconsistent with AIDS diagnosis. Further work-up led to diagnosis of toxic shock syndrome due to staphylococcal epidural abscess. The patient's lymphocyte count normalized with antibiotic treatment.