Back to Basics: Toxic Shock Syndrome

Toxic Shock Syndrome

Overview - caused by toxigenic strains of Staphylococcus aureus and Streptococcus pyogenes

  • Super-antigen mediated - toxins produced by bacteria cause T cell activation and massive cytokine release
  • Prodrome of fever, myalgias, malaise, headache, sore throat, GI symptoms—> hypotension and multi-organ dysfunction
  • Clinical Diagnosis!
  • Mortality rates: Staph <5% vs Strep 20-45%

Staphylococcus aureus mediated - most common type

  • Toxin shock syndrome toxin - 1 (TSST-1) and enterotoxin B
  • Risk factors - classically related to tampon usage; vaginal foreign body, nasal packing, wound infection, pneumonia
  • Sunburn-like rash - diffuse macular erythroderma involving palms and soles, desquamation after 1-2 weeks


  • Empirically cover for MRSA with vancomycin, add clindamycin as decreases toxin production
  • Source control - remove foreign body, wound debridement, drainage of abscess/infected fluid collection
  • Supportive care - aggressive crystalloid resuscitation +/- vasopressors ​

Streptococcus pyogenes toxic shock syndrome - less common

  • Similar in clinical course to Staph, although rash is uncommon
  • Mediated by exotoxins A & B
  • Associated with necrotizing soft tissue infections, myositis - look for pain out of proportion, local violaceous discoloration, crepitus, and bullae formation
  • >50% develop ARDS


  • Surgical consult for source control
  • Piperacillin-tazobactam + clindamycin, consider adding vancomycin to cover for MRSA if undifferentiated
  • Supportive care


Below is the case definition per Tintinalli, although not practical for ED diagnosis.

Clinical criteria:

  • Fever: temperature ≥38.9°C or 102.0°F
  • Rash: diffuse macular erythroderma
  • Desquamation: 1–2 weeks after onset of rash
  • Hypotension: systolic blood pressure ≤90 mm Hg (adult) or <5th percentile by age (children <16 years of age)
  • Multiorgan involvement (≥3 organ systems):

^ Gastrointestinal: vomiting and/or diarrhea at onset of illness
^ Muscular: severe myalgia or CPK ≥2 times the upper limit of normal
^ Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia
^ Renal: BUN or serum Cr ≥2 times the upper limit of normal for laboratory or urinary sediment with pyuria (≥5 leukocytes per high-power field) in the absence of urinary tract infection
^ Hepatic: total bilirubin, ALT, or AST ≥2 times the upper limit of normal
^ Hematologic: platelet count <100,000/mm3
^ Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent

Laboratory criteria - Negative results on the following tests, if obtained:

  • Blood or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus)
  • Serologies for Rocky Mountain spotted fever, leptospirosis, or measles

Case classification:

  • Probable: ≥4 clinical criteria + laboratory criteria met
  • Confirmed: 5 clinical criteria + laboratory criteria met, including desquamation (unless death occurs prior to desquamation)



Liang, S. “Toxic Shock Syndromes.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Ed. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.