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 nonspecific, but the course of the disease is precipitous and toxicity occurs early, resulting in serious life-threatening disease and multiorgan 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 nonmenstrual) is associated with extended tampon use, postpartum infections, and other sites of infection with the organism.
Treatment includes supportive care in an ICU, early empiric 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 nonspecific (e.g., fever, chills, myalgias, headache), the course of the disease is precipitous, and shock and multiorgan 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 nonmenstrual TSS, which can result from a variety of staphylococcal postpartum vaginal and cesarean wound infections.
History and exam
Key diagnostic factors
- severe diffuse or localized pain in an extremity
- localized 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, hematoma formation, or muscle strain
- surgical procedures (e.g., vaginal delivery, breast reconstruction, cesarean section, hysterectomy, liposuction, bunionectomy)
- single tampon used continuously for consecutive days during menses
- use of highly absorbent tampons
- NSAID use
- use of 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 BUN 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
Walid Khayr, MD
Professor of Medicine
Rosalind Franklin University of Medicine and Science
Infectious Disease Section Chief
Veteran Affairs Medical Center
WK declares that he has no competing interests.
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.
Mary Jane Reed, MD, FACS, FASMBS
Department of Critical Care Medicine and Department of General Surgery
Geisinger Medical Center
MJR declares that she has no competing interests.
Janice Zimmerman, MD
Critical Care Division
The Methodist Hospital
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)
DA is an author of a number of references cited in this topic.
- Gram-negative sepsis
- Rocky Mountain spotted fever (RMSF)
- Acute meningococcemia
- 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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