Chapter 60: Toxic Shock Syndrome

High-Yield Facts

• Toxic shock syndrome (TSS) is an acute, toxin-mediated illness characterized by fever, erythematous rash, hypotension, multi-organ involvement, and desquamation.

• Most cases of TSS have been associated with Staphylococcus aureus, However, Group A Streptococcus (GAS) can cause a similar disease known as streptococcal TSS (STSS).

• Menstrual and nonmenstrual cases of TSS are now reported with almost equal frequency. Predisposing factors for nonmenstrual TSS are surgical and nonsurgical trauma, burns, and postpartum conditions. Predisposing factors for STSS are varicella, NSAID use, and deep-seated GAS infections.

• STSS patients may have severe pain and hyperesthesia out of proportion to the degree of skin involvement.

• Management depends on prompt recognition, identification, and removal of the infectious focus. In addition, antibiotics and hemodynamic support are essential.

• Clindamycin has been recommended as the antibiotic of choice for both TSS and STSS (along with penicillin G for GAS).

• TSS can mimic many common diseases and should be considered in any patient who has unexplained fever, rash, and a toxic condition out of proportion to local findings.

Introduction

TSS is a rare acute febrile disease characterized by fever, diffuse erythroderma (that later desquamates), vomiting, abdominal pain, diarrhea, myalgia, and nonspecific neurologic abnormalities.¹ It can progress rapidly to hypotension, multi-organ failure, and death.²

It was first described in 1978 in seven children with S. aureus infections.³ An epidemic was noted in menstruating women associated with continuous tampon use in 1980. With the withdrawal of superabsorbent tampons from the market and other public health interventions, the incidence of menstrual TSS decreased from 13.7 per 100,000 persons in 1980 to 0.3 per 100,000 in 1986.^4,5 Nonmenstrual TSS has been described in both children and adults in various clinical scenarios ^6,7 Since 1987, a toxic shock-like syndrome similar to that attributable to staphylococcus has been reported due to highly invasive streptococcal infections. Several studies have reported that invasive STSS is more common in adults than children.^8–10 The Centers for Disease Control and Prevention (CDC) use “STSS” to distinguish streptococcal from TSS caused by staphylococcal infection in their case definition.¹¹

Because TSS and STSS are syndromes, the diagnosis is made when several clinical signs are found together (Tables 60-1 and 60-2 for CDC case definitions).^11,12 The rarity of such cases and the difficulty meeting the strict definition are reasons for the paucity of medical literature and specifically prospective studies on TSS. In addition, since 1986, there has not been ongoing population-based active surveillance to assess the incidence or disease burden of TSS.