Toxic shock syndrome

Last reviewed: 18 Apr 2022
Last updated: 16 Feb 2022

Summary

Definition

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

IL

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

PA

Disclosures

MJR declares that she has no competing interests.

Janice Zimmerman, MD

Head

Critical Care Division

The Methodist Hospital

Houston

TX

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.

  • Toxic shock syndrome images
  • 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
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer