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

Treatment

• 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

Treatment

• 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)

Reference:

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.