Tehran University of Medical Sciences Journal of Family and Reproductive Health 1735-8949 20 1 2026 07 22 78 82 EN Medha Gudavalli Department of Family Medicine, University of California San Diego, San Diego, California, United States of America Jenny Thai Department of Family Medicine, University of California San Diego, San Diego, California, United States of America Divya Reddy Department of Family Medicine, University of California San Diego, San Diego, California, United States of America Caitlin MacMillen Department of Family Medicine, University of California San Diego, San Diego, California, United States of America Michele Ritter Department of Infectious Diseases, University of California San Diego, San Diego, California, United States of America Madison Kent Department of Obstetrics and Gynecology, University of California San Diego, San Diego, California, United States of America 2026 03 31 2026 06 09 Objective: To describe a rare case of non-menstrual staphylococcal toxic shock syndrome (TSS) with Staphylococcus aureus urinary tract infection as the suspected primary source and to highlight the successful use of linezolid as adjunctive therapy when clindamycin resistance is present. Case report: A 42-year-old woman presented with fever, vomiting, diarrhea, and severe vulvar pain. One month prior, she experienced vaginal pruritus with excoriations and fissuring that never fully resolved. On examination, she had conjunctival injection, tongue inflammation with non-vesicular lesions, and a diffuse erythematous macular rash. Laboratory evaluation revealed elevated transaminases, thrombocytopenia, and bandemia. Urinalysis demonstrated 100,000 CFU of Staphylococcus aureus. Gynecologic examination revealed vulvar and vaginal erythema with ulcerated cervical lesions. Vaginal culture also grew heavy Staphylococcus aureus. Given the constellation of fever, rash, mucosal involvement, hepatic dysfunction, and positive Staphylococcus aureus cultures, a diagnosis of toxic shock syndrome was made. The isolate was resistant to clindamycin, necessitating treatment with vancomycin, piperacillin-tazobactam, and linezolid. The patient improved and completed 14 days of antibiotic therapy with complete resolution of symptoms. Conclusion: Staphylococcus aureus urinary tract infection is an exceedingly rare source of toxic shock syndrome. Clinicians should maintain a high index of suspicion for TSS in patients with any staphylococcal infection presenting with fever and multisystem involvement. Linezolid is an effective alternative to clindamycin for toxin suppression, particularly in cases involving clindamycin-resistant organisms. Prior mucosal barrier disruption may be an important risk factor for TSS development. https://jfrh.tums.ac.ir/index.php/jfrh/article/view/3687 https://jfrh.tums.ac.ir/index.php/jfrh/article/download/3687/756