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.
Toxic shock syndrome (TSS) is an exotoxin-mediated illness caused by bacterial infection. Organisms commonly responsible include group A streptococcus (Streptococcus pyogenes), or methicillin-sensitive (MSSA) or methicillin-resistant (MRSA) Staphylococcus aureus. 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.
History and exam
Key diagnostic factors
- severe diffuse or localised pain in an extremity
- localised swelling or erythema
- diffuse, scarlatina-like erythematous rash
Other diagnostic factors
- acute mental status changes
- influenza-like symptoms
- muscular tenderness and weakness
- abdominal pain and tenderness
- features of myocarditis
- diabetes mellitus
- 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
1st investigations to order
- microscopy and culture (blood, wound, fluid, tissue)
- prothrombin time
- partial thromboplastin time
- serum urea and creatinine
- creatine kinase (CK)
- serum calcium
- serum albumin
- serum lactic acid
Investigations to consider
- Staphylococcus aureus antibody testing
- chest x-ray
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
- Gram-negative sepsis
- Rocky Mountain spotted fever (RMSF)
- Acute meningococcaemia
- 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
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