Toxic Shock Syndrome

Introduction

What is toxic shock syndrome (TSS)?

It is a potentially fatal infection resulting from a bacterial toxin.

What causes TSS?

It is caused by various organisms like Staphylococcus aureus and group A Streptococcus pyogenes.

What are the Signs and Symptoms of Toxic Shock Syndrome?

The case definition requires all 3 manifestations of fever, hypotension, and diffuse scarlatiniform rash (erythema, which blanches and desquamates one or two weeks after onset of illness). It presents with various signs of infection, hemodynamic dysfunction, and organ failure.²

As per the CDC¹, there should be involvement of more than 3 extra-cutaneous organs for a diagnosis. These include:

• gastrointestinal (vomiting or diarrhea at onset of illness),
• muscular (severe myalgia or creatine phosphokinase level >2 times the upper normal limit),
• mucous membrane (vaginal, oropharyngeal or conjunctival hyperemia),
• renal (blood urea nitrogen or creatinine levels >2 times upper normal limit or >5 leukocytes per high-power field in the absence of a urinary tract infection),
• hepatic (total bilirubin, serum aspartate aminotransferase or serum alanine aminotransferase levels >2 times the upper normal limit),
• hematologic (platelets <100,000 per cumm),
• central nervous system (disorientation or alterations in consciousness without focal neurological signs when fever and hypotension are absent).

Investigations

Leucocytosis, thrombocytopenia, elevated transaminases, azotemia, hematuria, pyuria are just some of the findings in most of the cases.¹ Negative results on the following tests: Blood, throat, or cerebrospinal fluid cultures are often observed. Serological tests for Rocky Mountain spotted fever, leptospirosis or measles should be done to rule them out.¹

Differential Diagnosis

TSS is most often seen in the menstruating women who use tampons. However, it is not uncommon in children. The milder form of the disease is often confused with Kawasaki disease and Scarlet fever.¹

Treatment

Treatment of TSS includes close monitoring of the patient along with the elimination of the localized infection focus (skin or soft tissue). Supportive treatment should be started for any renal insufficiency and hypotension.¹ Supportive management is required in case of multiple organ failures. Antibiotics are used to eliminate staphylococcal or streptococcal infections which reduce mortality. Vancomycin and clindamycin are often used.^1,2 Corticosteroids and IVIG may be useful.³