DEFINITIONToxic shock syndrome (TSS) is an acute febrile illness resulting in multiple organ system dysfunction caused most commonly by a bacterial exotoxin. Disease characteristics also include hy-potension, vomiting, myalgia, watery diarrhea, vascular col-lapse, and an erythematous sunburn-like cutaneous rash that desquamates during recovery.PHYSICAL FINDINGS AND CLINICAL PRESENTATION Fever (38.9 C) Diffuse macular erythrodermatous rash that desquamates 1

to 2 weeks after disease onset in survivors (Fig. 3521) Orthostatic hypotension GI symptoms: vomiting, diarrhea, abdominal tenderness Constitutional symptoms: myalgia, headache, photopho-

bia, rigors, altered sensorium, conjunctivitis, arthralgia Respiratory symptoms: dysphagia, pharyngeal hyperemia,

strawberry tongue Genitourinary symptoms: vaginal discharge, vaginal hyper-

emia, adnexal tenderness End-organ failure Severe hypotension and acute renal failure Hepatic failure Cardiovascular symptoms: DIC, pulmonary edema, ARDS,

endomyocarditis, heart blockCAUSE Menstrually associated TSS: 45% of cases associated with

tampons, diaphragm, or vaginal sponge use Nonmenstruating associated TSS: 55% of cases associated

with puerperal sepsis, post cesarean section endometritis, mastitis, wound or skin infection, insect bite, pelvic in am-matory disease, and postoperative fever

Causative agent: S. aureus infection of a susceptible indi-vidual (10% of population lacking suf cient levels of anti-toxin antibodies), which liberates the disease mediator TSST-1 (exotoxin)

Other causative agents: coagulase-negative streptococci pro-ducing enterotoxins B or C, and exotoxin A producing group A -hemolytic streptococci

DIFFERENTIAL DIAGNOSIS Staphylococcal food poisoning Septic shock Scarlet fever Rocky Mountain spotted fever Meningococcemia Toxic epidermal necrolysis Kawasakis syndrome Leptospirosis Legionnaires disease Hemolytic-uremic syndrome Stevens-Johnson syndrome Scalded skin syndrome Erythema multiforme Acute rheumatic feverWORKUPBroad-spectrum syndrome with multiorgan system involve-ment and variable but acute clinical presentation, including the following:1. Fever 38.1 C2. Classic desquamating (1 to 2 weeks) rash3. Hypotension/orthostatic SBP 90 or less4. Syncope5. Negative throat/CSF cultures

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352 Section 14: Infectious diseases

Chapter 352 Toxic shock syndrome

Fig 3521Cutaneous changes in toxic shock. (A) Localized infection at the edge of a patch of eczema in a patient presenting with staphylococcal toxic shock syndrome. (B) Desquamation of the palm following an episode of staphylococcal toxic shock.(Courtesy of M. Jacobs, London, UK.)

AB

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Chapter 352: Toxic shock syndrome 3526. Negative serologic test for Rocky Mountain spotted fever,

rubeola, and leptospirosis7. Clinical involvement of three or more of the following:

a. Cardiopulmonary: ARDS, pulmonary edema, endomyo-carditis, second- or third-degree atrioventricular blockb. CNS: altered sensorium without focal neurologic ndingsc. Hematologic: thrombocytopenia (platelets 100,000)d. Liver: elevated LFT resultse. Renal: 5 WBC/high-power eld (HPF), negative urine cultures, azotemia, and increased creatinine double normalf. Mucous membrane involvement: vagina, oropharynx, conjunctivag. Musculoskeletal: myalgia, CPK twice normalh. GI: vomiting, diarrhea

LABORATORY TESTS Pan culture (cervix/vagina, throat, nasal passages, urine,

blood, CSF, wound) for Staphylococcus, Streptococcus, or other pathogenic organisms

Electrolytes to detect hypokalemia, hyponatremia CBC with differential and clotting pro le for anemia

(normocytic/normochromic), thrombocytopenia, leukocy-tosis, coagulopathy, and bacteremia

Chemistry pro le to detect decreased protein, increased AST, increased ALT, hypocalcemia, elevated BUN/creatinine, hypophosphatemia, increased LDH, increased CPK

Urinalysis to detect WBC (5/HPF), proteinemia, microhe-maturia

ABGs to assess respiratory function and acid-base status Serologic tests considered for Rocky Mountain spotted fever,

rubeola, and leptospirosis

IMAGING STUDIES Chest x-ray to evaluate pulmonary edema ECG to evaluate arrhythmia Sonography/CT scan/MRI considered if pelvic abscess or

TOA suspectedTREATMENT Aggressive uid resuscitation (maintenance of circulating

volume, CO, systolic blood pressure) Thorough search for a localized infection or nidus: incision

and drainage, debridement, removal of tampon or vaginal sponge

Isotonic crystalloid (normal saline solution) for volume re-placement

Electrolyte replacement (K, Ca2) PRBC/coagulation factor replacement/FFP to treat anemia

or D&C Vasopressor therapy for hypotension refractory to uid vol-

ume replacement Parenteral antibiotic therapy; -lactamase resistant antibi-

otic (methicillin, nafcillin, or oxacillin) initiated early

REFERENCESBryan CS: Infectious Diseases in Primary Care, Philadelphia, WB Saun-

ders, 2002.Cohen J, Powderly WG: Infectious Diseases, 2nd ed. St Louis, Mosby,

2004.Ferri F: Ferris Clinical Advisor 2007. St Louis, Mosby, 2007.Ferri F: Practical Guide to the Care of the Medical Patient, 7th ed.

St Louis, Mosby, 2007.

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