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Chapter 88: Toxic Shock Syndromes

Sorabh Khandelwal

STAPHYLOCOCCAL TOXIC SHOCK SYNDROME

Staphylococcal toxic shock syndrome (TSS) is a severe, life-threatening infection attributed to Staphylococcus aureus that can progress rapidly to multisystem dysfunction, severe electrolyte disturbances, renal failure, and shock. Risk factors for TSS include retained foreign bodies (e.g., tampons, female barrier contraceptives), skin and soft tissue infections (e.g., abscess, cellulitis, and mastitis), varicella infection, sinusitis, surgery, trauma, childbirth, and influenza.

Clinical Features

TSS is characterized by high fever, profound hypotension, diffuse macular rash, desquamation (1 to 2 weeks after onset of rash), and multiorgan dysfunction. The details regarding the diagnostic criteria for TSS are listed in Table 88-1. Patients presenting early in the course may exhibit nonspecific symptoms such as fever, chills, malaise, myalgias, headache, sore throat, vomiting, diarrhea, or abdominal pain. The rash associated with TSS is described as a “painless sunburn” that typically fades within 3 days and is followed by full-thickness desquamation.

Table 88-1

Case Definition for Toxic Shock Syndrome

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Table 88-1

Case Definition for Toxic Shock Syndrome

  • 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)

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CPK, creatine phosphokinase; Cr, creatinine.

Diagnosis and Differential

TSS is a clinical diagnosis characterized by an acute febrile illness associated with erythroderma, hypotension, and multiorgan involvement. Laboratory evaluation reveals evidence of end-organ damage, and testing often includes CBC, comprehensive metabolic panel, coagulation studies, creatine phosphokinase level, urinalysis, chest radiograph, ECG, blood gas, and cultures of blood and other potential sites of infection. Other infections to consider in the differential diagnosis of TSS include streptococcal toxic shock syndrome (STSS), myonecrosis due to Clostridium perfringens, TSS due to Clostridium sordellii, staphylococcal ...

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