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Toxic shock syndrome

Last reviewed: 4 Sep 2023
Last updated: 17 May 2023



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
  • gastrointestinal symptoms
  • features of myocarditis
  • endophthalmitis
  • hypothermia
Other diagnostic factors

Risk factors

  • diabetes mellitus
  • alcohol-use disorder
  • minor trauma and injuries with bruising, hematoma formation, or muscle strain
  • surgical procedures (e.g., vaginal delivery, breast reconstruction, cesarean section, hysterectomy, liposuction, bunionectomy)
  • prolonged use (>6 hours) of single tampon
  • use of highly absorbent tampons
  • nonsteroidal anti-inflammatory drug (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
  • coagulation profile
  • serum BUN and creatinine
  • urinalysis
  • LFTs
  • creatine kinase (CK)
  • serum calcium
  • serum sodium
  • serum phosphorus
  • 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



Brit Jeffrey Long, MD

​Attending Physician

Associate Professor of Emergency Medicine

Department of Emergency Medicine

Brooke Army Medical Center

Fort Sam Houston



BJL declares that he has no competing interests.


Dr Brit J. Long would like to gratefully acknowledge Dr Marie R. Baldisseri and Dr Walid Khayr, previous contributors to this topic.


MRB and WK declare they have 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
    • Invasive group A streptococcal disease: management and chemoprophylaxis
    More Guidelines
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