Toxic shock syndrome

Last reviewed: 28 Feb 2023
Last updated: 16 Feb 2022



History and exam

Key diagnostic factors

  • severe diffuse or localized pain in an extremity
  • fever
  • localized 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, 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
More risk factors

Diagnostic investigations

1st investigations to order

  • microscopy and culture (blood, wound, fluid, tissue)
  • CBC
  • prothrombin time
  • partial thromboplastin time
  • serum BUN 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


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

North Chicago



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.

Peer reviewers

Mary Jane Reed, MD, FACS, FASMBS

Associate Professor

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.

  • Toxic shock syndrome images
  • Differentials

    • Gram-negative sepsis
    • Rocky Mountain spotted fever (RMSF)
    • Acute meningococcemia
    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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