Infectious Disease Compendium

Toxic Shock Syndrome

Diagnosis

There is Streptococcal and S. aureus. See each organism for details. It is due to a super-antigen that activates up to 20% the lymphocytes at once.

CDC case definition, which not everyone will meet.

  1. Body temperature > 38.9 °C (102.02 °F)
  2. Systolic blood pressure < 90 mmHg
  3. Diffuse macular erythroderma
  4. Desquamation (especially of the palms and soles) 1–2 weeks after onset
  5. Involvement of three or more organ systems:
  • Gastrointestinal (vomiting, diarrhea)
  • Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal for laboratory
  • Mucous membrane hyperemia (vaginal, oral, conjunctival). The strawberry tongue.
  • Kidney failure (serum creatinine > 2 times normal)
  • Liver inflammation (bilirubin, AST, or ALT > 2 times normal)
  • Low platelet count (platelet count < 100,000 / mm3)
  • Central nervous system involvement (confusion without any focal neurological findings) Negative results of: Blood, throat, and CSF cultures for other bacteria (besides S. aureus)

6. Negative serology for Rickettsia infection, leptospirosis, and measles

Cases are classified as confirmed or probable as follows:

Confirmed: All six of the criteria above are met (unless the patient dies before desquamation can occur)

Probable: Five of the six criteria above are met

Epidemiologic Risks

The Streptococcal form is associated with clinical infection often necrotizing fasciitis or myositis, and rarely with strep throat (The use of NSAIDs is highly associated with the development of Streptococcal necrotizing fasciitis).

The Staphylococcal is not always associated with an obvious infection; half of Staphylococcal toxic shock syndromes are due to tampons, half are due to surgical wound infections, which usually occur within 48 hours after surgery. Classic is with nasal packing, the tampon equivalent.

In both cases, there is MOSF with a sunburn rash that involves the palms and soles. I had one patient who was so clamped down due to pressers he did not develop a rash until the pressers were weaned off and he re-perfused his skin.

A low calcium is a hint.

It occurs in those with no preexisting antibody from prior exposure and there are occasional repeat cases in those that do not make an antibody to the toxin.

Microbiology

Group A streptococci or S. aureus.

Empiric Therapy

Nafcillin / oxacillin OR cefazolin OR vancomycin PLUS clindamycin (900 mg q 8) PLUS IVIG (1 gram/kg on day one and 0.5 gm/kg on day 2 and 3 (PubMed)) PLUS debridement.

IVIG may not help in children for Group A strep (PubMed) but a meta-analysis found it halved the mortality (PubMed) "with remarkable consistency across the single randomized and four nonrandomized studies."

See each organism for details.

Pearls

Debridement is key. No debridement and the patient will die. And with wound associated TSS, the source DOES NOT LOOK INFECTED. It still HAS TO BE DEBRIDED. The caps are there for a purpose. Pay attention.

Not all IVIG preparations have the same anti-TSST activity (PubMed), so the response could be less than you would hope.

Curious Cases

Relevant links to my Medscape blog

Shock

Once, Twice, Three Times a Toxin

Close Enough

Apeeling

Last Update: 03/10/19.