Toxic shock syndrome (TSS) is a severe, life-threatening syndrome that can progress rapidly to multisystem dysfunction, severe electrolyte disturbances, renal failure and shock. Colonization or infection by Staphylococcus aureus has been implicated in the majority of cases. Although TSS was initially related to menstruating females, now the spectrum of patients at risk includes both genders and all ages. Risk factors for TSS includes recent menstruation, postpartum or postabortion status, cutaneous lesions such as burns, tattoos, piercings, varicella lesions or recent surgical sites, and intracavitary foreign objects such as nasal packing, intrauterine devices, and vaginal sponges.
TSS is characterized by high fever, profound hypotension, diffuse erythrodermatous rash, mucus membrane hyperemia, diffuse myalgias, nonfocal neurologic abnormalities to include lethargy, agitation, confusion, headache or seizures, vomiting, diarrhea or abdominal pain that can rapidly progresses to multisystem dysfunction, organ failure, and death. The rash associated with TSS is described as a “painless sunburn” that typically fades within 3 days and is followed by full-thickness desquamation.
Diagnosis and Differential
TSS must be considered in any acute febrile illness associated with erythroderma, hypotension, and multiorgan involvement. Diagnostic criteria are listed in Table 88-1. When considering TSS, the evaluation should include arterial blood gas analysis; a complete blood count with a differential count; electrolyte determinations, including magnesium, calcium, creatinine phosphokinase; coagulation panel; urinalysis; electrocardiogram; and a chest x-ray. If neurologic abnormalities are present, a head CT and lumbar puncture should be considered. Other syndromes to consider in the differential diagnosis of TSS include streptococcal TSS (STSS), Kawasaki disease, staphylococcal scalded skin syndrome, Rocky Mountain spotted fever, and septic shock.
Table 88-1 Diagnostic Criteria for Toxic Shock Syndrome |Favorite Table|Download (.pdf)
Table 88-1 Diagnostic Criteria for Toxic Shock Syndrome
|1. Fever: temperature ≥ 38.9°C (≥ 102.0°F)|
|2. Rash: diffuse macular erythroderma|
|3. Desquamation: 1 to 2 wk after onset of illness|
|5. Multisystem involvement (≥ 3 of the following)
Gastrointestinal: vomiting or diarrhea at onset of illness
Muscular: severe myalgias or creatine kinase elevation twice the normal level
Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia
Renal: serum urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria (≥ 5 leukocytes/high power field) in the absence of urinary tract infection
Hepatic: total bilirubin, alanine aminotransferase enzyme, or aspartate aminotransferase enzyme levels at least twice the upper limit of normal for the laboratory
Hematologic: platelets < 100 000/mL
Central nervous system: disorientation or alterations in consciousness
|6. Laboratory criteria: negative CSF, blood, or throat cultures (if collected) for any organism except Staphylococcus Aureus|