Toxic shock syndrome

Last reviewed: 7 Jan 2023

Last updated: 16 Feb 2022

Toxic shock syndrome (TSS) is an exotoxin-mediated illness caused by bacterial infection, most commonly group A streptococcus or Staphylococcus aureus.

Presenting signs and symptoms can be non-specific, but the course of the disease is precipitous and toxicity occurs early, resulting in serious life-threatening disease and multi-organ system failure.

Early diagnosis and treatment is essential.

Streptococcal TSS can occur with infection at any site but is more commonly associated with an infected cutaneous site.

Staphylococcal TSS (menstrual or non-menstrual) is associated with extended tampon use, postpartum infections, and other sites of infection with the organism.

Treatment includes supportive care in an ICU, early empirical antibiotic treatment, and further culture-sensitive antibiotic treatment. Surgical debridement may be needed for deep-seated streptococcal infections.

Definition

Toxic shock syndrome (TSS) is an exotoxin-mediated illness caused by bacterial infection. Organisms commonly responsible include group A streptococcus (Streptococcus pyogenes),[1][2] or methicillin-sensitive (MSSA) or methicillin-resistant (MRSA) Staphylococcus aureus.[3] Although the presenting signs and symptoms can be non-specific (e.g., fever, chills, myalgias, headache), the course of the disease is precipitous, and shock and multi-organ system failure occur early in the course of the disease.

Staphylococcal TSS can be split into 2 groups: menstrual TSS, which occurs in women during menstruation with extended use of a single tampon or, historically, with highly absorbable tampons; and non-menstrual TSS, which can result from a variety of staphylococcal post-partum vaginal and caesarean wound infections.[4][5][6][7][8]

History and exam

Key diagnostic factors

severe diffuse or localised pain in an extremity
fever
localised swelling or erythema
hypotension
diffuse, scarlatina-like erythematous rash

More key diagnostic factors

Other diagnostic factors

acute mental status changes
influenza-like symptoms
muscular tenderness and weakness
abdominal pain and tenderness
features of myocarditis
endophthalmitis
hypothermia

Other diagnostic factors

Risk factors

diabetes mellitus
alcoholism
minor trauma and injuries with bruising, haematoma formation, or muscle strain
surgical procedures (e.g., vaginal delivery, breast reconstruction, caesarean section, hysterectomy, liposuction, bunionectomy)
single tampon used continuously for consecutive days during menses
using highly absorbent tampons
NSAID use
using contraceptive sponges, diaphragms, and IUDs
untreated strep throat

More risk factors

Diagnostic investigations

1st investigations to order

microscopy and culture (blood, wound, fluid, tissue)
FBC
prothrombin time
partial thromboplastin time
serum urea and creatinine
urinalysis
LFTs
creatine kinase (CK)
serum calcium
serum albumin
serum lactic acid

More 1st investigations to order

Investigations to consider

Staphylococcus aureus antibody testing
chest x-ray

More investigations to consider

Emerging tests

serotyping

Treatment algorithm

INITIAL

suspected toxic shock syndrome

ACUTE

confirmed streptococcal toxic shock syndrome

confirmed staphylococcal toxic shock syndrome: methicillin-sensitive

confirmed staphylococcal toxic shock syndrome: methicillin-resistant

clinical toxic shock syndrome without confirmed cultures

Contributors

Authors

Walid Khayr, MD

Professor of Medicine

Rosalind Franklin University of Medicine and Science

Infectious Disease Section Chief

Veteran Affairs Medical Center

North Chicago

Disclosures

WK declares that he has no competing interests.

Acknowledgements

Dr Khayr would like to gratefully acknowledge Dr Marie R. Baldisseri, a previous contributor to this topic. MRB declares that she has no competing interests.

Peer reviewers

Mary Jane Reed, MD, FACS, FASMBS

Associate Professor

Department of Critical Care Medicine and Department of General Surgery

Geisinger Medical Center

Danville

Disclosures

MJR declares that she has no competing interests.

Janice Zimmerman, MD

Head

Critical Care Division

The Methodist Hospital

Houston

Disclosures

JZ declares that she has no competing interests.

Djillali Annane, MD, PhD

Professor in Medicine at University of Versailles SQY

Director of the General ICU at Raymond Poincaré Hospital (AP-HP)

Director of the Center for Clinical Research and Technology Innovation (INSERM)

Garches

France

Disclosures

DA is an author of a number of references cited in this topic.

Differentials
- Gram-negative sepsis
- Rocky Mountain spotted fever (RMSF)
- Acute meningococcaemia
More Differentials
Guidelines
- Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2021
- World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E) consensus conference: recommendations for the management of skin and soft-tissue infections
More Guidelines
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Toxic shock syndrome

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

suspected toxic shock syndrome

confirmed streptococcal toxic shock syndrome

confirmed staphylococcal toxic shock syndrome: methicillin-sensitive

confirmed staphylococcal toxic shock syndrome: methicillin-resistant

clinical toxic shock syndrome without confirmed cultures

Contributors

Authors

Walid Khayr, MD

Disclosures

Acknowledgements

Peer reviewers

Mary Jane Reed, MD, FACS, FASMBS

Disclosures

Janice Zimmerman, MD

Disclosures

Djillali Annane, MD, PhD

Disclosures

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

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