Both TSS and STSS are characterized by an acute illness with fever, hypotension, and multisystem organ involvement (including renal failure). Because this can be difficult to distinguish from other childhood illnesses in their early stages, the CDC has established clinical criteria for diagnosis, which may not be applicable to children. Thus, in 1990, abbreviated diagnostic criteria were proposed for use in children (Table 60-3).19
TABLE 60-3Abbreviated Criteria for Diagnosis of TSS in Children ||Download (.pdf) TABLE 60-3 Abbreviated Criteria for Diagnosis of TSS in Children
Diarrhea ± vomiting
TSS should be considered in any patient who has unexplained fever, rash, and a toxic appearance. Patients with menstrual TSS usually present between the third and fifth day of menses. For a child there may be a sudden onset of high fever, over 38.9°C (with chills), vomiting, diarrhea, myalgia, dizziness, and diffuse rash. Additional signs and symptoms may include headache, arthralgia, sore throat, abdominal pain, stiff neck with orthostatic dizziness or syncope. Diarrhea (which may be profuse and watery) and vomiting occur in about half of the cases.13
Physical examination may reveal hypotension or orthostatic blood pressure changes. In the acute stage, which lasts 24 to 48 hours, the patient may be agitated, disoriented, or obtunded. Hyperemia of the conjunctiva and vagina is seen (Fig. 60-1). Tender edematous external genitalia, vaginal mucosal erythema, scant purulent cervical discharge, and bilateral–adnexal tenderness are seen in menstruation-related TSS.
Erythema of the bulbar conjunctivae associated with facial erythema and edema in a female with menstrual TSS. (Figure 22-34 Reproduced with permission from Wolff K, et al: Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology, 6th edition. McGraw-Hill; 2009)
Skin findings can be dramatic and present as a severe erythroderma and erythema of mucus membranes (Fig. 60-2).
Blanching, nonpruritic erythroderma with a “rough” texture in a patient with toxic shock syndrome. (Figure 246-3 Reproduced with permission from Tintinalli JE, et al: Emergency Medicine A Comprehensive Study Guide, 6th edition. McGraw-Hill; 2004.)
Between the fifth and tenth hospital day, a generalized pruritic maculopapular rash develops in about 25% of patients. The skin rash is diffuse and blanches. It fades within 3 days of its appearance and is followed by a fine generalized desquamation of the skin, with peeling over the soles, fingers, toes, and palms.
Nonspecific, but frequently found abnormal laboratory values reflect the multisystem involvement in TSS. Leukocytosis, with an increase in immature forms, is frequently seen. Lymphopenia has been reported as a useful way to confirm diagnosis. Platelet count may be low. Azotemia and abnormal urinary sediment are seen with the development of acute renal failure. Liver function tests frequently show some elevation of liver enzymes and bilirubin. Electrolyte abnormalities vary and may include hyponatremia. With severe hypotension, the patient may be acidotic. Clotting studies are normal or mildly abnormal; untreated patients may show clinical evidence of coagulopathy. Cultures of blood, throat, and cerebrospinal fluid may be useful. Vaginal culture should be done, as well as culture from any identifiable focus of infection. Staphylococcus will be cultured from the cervix or vagina of more than 85% of patients with menstrual TSS. The majority of the above tests return to normal by 7 to 10 days after onset of illness.
Mild episodes of TSS are more difficult to diagnose. The presence of any combination of fever, headache, sore throat, diarrhea, vomiting, orthostatic dizziness, syncope, or myalgias in a menstruating woman should raise the possibility of TSS. The presence of S. aureus on culture is not diagnostic because non-TSST-1–producing S. aureus may be cultured from the cervix or vagina of up to 10% of well women. However, the presence of desquamation during a febrile illness should prompt the clinician to obtain cultures for S. aureus. Other laboratory data do not reflect multisystem involvement in mild cases. Thus, strong support for mild TSS will depend on the development of the typical desquamation of palms, soles, toes, and fingers.
STSS presents as sudden onset of shock and organ failure in the presence of any streptococcal infection. Tender erythroderma is the most suggestive symptom of STSS. It appears abruptly and the hyperesthesia may seem out of proportion to the degree of skin involvement. These patients should be evaluated for GAS necrotizing fasciitis.2 STTS, compared to staphylococcal TSS, is often associated with focal tissue infection and bacteremia with more fulminant course and greater mortality.20
The initial presentation of STSS may not be obvious; those most suspect includes children with varicella, skin injury, well-localized or unusually severe tenderness, and infection at sites of blunt trauma.