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Toxic Shock Syndrome

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Patients can die quickly. Seen in children or young adults with all but a minor skin wound or tampon with a super antigen. Volume replace, do have they a rash or diarrhoea. If you think it could be then give fluids and get help.

Initial Shock Management: Oxygen 15 L/min unless COPD.
ABC, IV access x 2. Start IV N-Saline. Culture, IV antibiotics Refer ITU. Eliminate source of toxin where possible Send FBC, U&E, LFT, Group and hold +/- Lactate, Trop, Dimer, ABG Consider Urinary catheter to measure urine output Fever, Temp, Sepsis, Tampon, Wound: Lactate Give IV Fluids and Antibiotics and consider IVIG

About

TSS is an acute, noncontagious systemic illness
Potentially fatal syndrome seen in all ages. The early signs may be subtle. It may appear like a septic shock but the blood cultures may be negative only on the considerations discussed above
Toxic shock syndrome is not restricted to menstruating females with tampons. Mortality is estimated at 2.5 %

Epidemiology

TSS is a very rare illness - much rarer than one would predict based.
It can occur in a simple seemingly unimportant wound infection in a young healthy male or female.
Staphylococcal TSS can be seen in males and adolescents.

Aetiology

Etiology	Pathophysiology
Staphylococcus aureus	Staph aureus produces toxic shock syndrome toxin-1 (TSST-1) and other enterotoxins. TSST-1 acts as a superantigen, bypassing normal antigen presentation processes. Massive activation of T-cells occurs, leading to a cytokine storm (release of large amounts of inflammatory cytokines). This cytokine release results in widespread inflammation, vasodilation, and capillary leak, leading to hypotension and shock. Multiorgan failure can occur due to severe hypotension and poor tissue perfusion.
Streptococcus pyogenes (Group A Streptococcus)	Strep pyogenes produces strep pyrogenic exotoxins (SPEs), including SPE-A, SPE-B, and SPE-C. Exotoxins act as superantigens, with activation of T-cells and excessive cytokine production. A cytokine storm causes systemic inflammation, similar to staph TSS, but more severe clinical manifestations. Severe soft tissue infections, such as necrotizing fasciitis, can be a source of toxin production, with shock and organ failure. Inflammatory mediators result in vasodilation, capillary leak, hypotension, and multi-organ dysfunction.
Other Bacterial Causes	Although less common, TSS can also be caused by other bacteria, including other streptococcal species or mixed bacterial infections. These bacteria may produce similar superantigens or other toxins that trigger a systemic inflammatory response. The pathophysiology remains similar, with toxin-mediated T-cell activation, cytokine storm, and resultant hypotension, shock, and organ failure. In cases associated with invasive procedures, childbirth, or wounds, the source of the infection may be localized but can lead to systemic effects.

Risk groups

Females who are either menstruating or postpartum
Females using barrier contraceptives
Postoperative patients
Patients with varicella or Herpes zoster infection
Patients with chemical or thermal burns

Case Definition

Criteria	Description
Fever	Temp ≥38.9°C (≥102°F).
Rash	Diffuse macular erythema (red rash), often described as "sunburn-like". May be subsequent desquamation (peeling) of the skin, palms and soles, 1-2 weeks after onset.
Hypotension	SBP ≤90 mmHg for adults or below the 5th percentile by age in children. Orthostatic syncope or dizziness indicative of hypotension.
Multiorgan Involvement (at least three of the following)	Gastrointestinal: Vomiting or diarrhea at onset of illness. Muscular: Severe myalgia (muscle pain) or elevated creatine kinase (≥2 times the upper limit of normal). Mucous Membranes: Hyperemia (redness) of the conjunctivae, oropharynx, or vagina. Renal: Blood urea nitrogen (BUN) or serum creatinine ≥2 times the upper limit of normal or sterile pyuria (≥5 white blood cells per high-power field). Hepatic: Elevated serum bilirubin, AST, or ALT ≥2 times the upper limit of normal. Haematologic: Platelets <100,000/mm³ (thrombocytopenia). CNS: Altered mental status without focal neurological signs when febrile and in the absence of hypotension.
Exclusion of Other Diseases	No other identified etiology or laboratory evidence that would explain the illness (e.g., measles, leptospirosis, Rocky Mountain spotted fever).
Laboratory Criteria	Isolation of Staphylococcus aureus or Streptococcus pyogenes from normally sterile sites (e.g., blood, CSF), although cultures may be negative in TSS cases.

Clinical

Causes high fever, hypotension, rash, multi-organ dysfunction
Cutaneous desquamation during the early convalescent periods
Hypotension and Tachycardia and warm peripheries possibly
Erythematous macular rash, Pyrexia, Agitation, Delirium
Vaginal speculum examination to detect and remove any retained tampon
The site of staphylococcal colonisation may appear entirely benign

Investigations

Bloods will show a greatly elevated neutrophils count.
Elevated prothrombin time and coagulopathy
Hypoalbuminemia, hypocalcemia, and pyuria.
Elevated CRP
Renal failure

Differential Diagnosis

Differential Diagnosis	Details
Septic Shock	A severe systemic infection causing organ dysfunction and persistent hypotension despite fluid resuscitation. Characterized by fever, chills, tachycardia, hypotension, and altered mental status. Can be caused by a variety of pathogens, including bacteria, viruses, and fungi.
Rocky Mountain Spotted Fever (RMSF)	A tick-borne illness caused by Rickettsia rickettsia. Presents with fever, rash (starting on wrists and ankles), and a history of tick exposure. Rash progresses to involve palms and soles, which can resemble the rash seen in TSS.
Kawasaki Disease	A paediatric vasculitis syndrome characterized by fever, conjunctivitis, rash, and mucous membrane changes. Can present with similar symptoms to TSS, including rash, fever, and lymphadenopathy. Distinguishing features include coronary artery involvement and prolonged fever.
Leptospirosis	A bacterial infection caused by Leptospira species, often acquired through contact with contaminated water. Presents with fever, myalgia, jaundice, conjunctival suffusion, and sometimes a rash. Can progress to Weil's disease, characterized by renal failure, jaundice, and haemorrhage.
Measles	A viral infection characterized by fever, cough, coryza, conjunctivitis, and a maculopapular rash that starts on the face and spreads downward. Rash can be confused with TSS, but measles typically involves Koplik spots (white lesions in the mouth).
Scarlet Fever	A bacterial illness caused by Streptococcus pyogenes producing erythrogenic toxin. Presents with fever, sore throat, and a characteristic "sandpaper-like" rash. Rash often starts on the trunk and spreads, with associated "strawberry tongue".
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)	A severe drug reaction characterized by fever, rash, lymphadenopathy, and internal organ involvement. Typically occurs 2-6 weeks after starting a new medication. Distinguishing features include eosinophilia and elevated liver enzymes.
Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN)	Severe mucocutaneous reactions often triggered by medications or infections. Presents with fever, rash, and mucous membrane involvement, leading to skin detachment. Distinguishing features include painful red or purpuric macules that progress to blisters and skin sloughing.

Complications

Acute Kidney injury, Rhabdomyolysis, Acute liver failure
Prolonged APTT but PT and fibrinogen normal

Management

Cause	Description	Management
Staphylococcus aureus	Most common cause of TSS. Toxin-mediated condition, often linked to tampon use, surgical wounds, and skin infections. Produces toxic shock syndrome toxin-1 (TSST-1) and other enterotoxins.	Immediate removal of the source (e.g., tampon, nasal packing, surgical debridement). IV fluids to correct hypotension and prevent organ failure. Empiric antibiotic therapy (e.g., clindamycin/vancomycin) to cover Staphylococcus aureus. IV immunoglobulin (IVIG) in severe cases to neutralize toxins. Supportive care in an intensive care unit (ICU) setting.
Streptococcus pyogenes (Group A Streptococcus)	A cause of TSS, associated with skin and soft tissue infections, such as necrotizing fasciitis. Produces streptococcal pyrogenic exotoxins (SPEs) that lead to systemic inflammation and shock.	Immediate surgical debridement of infected tissue to remove the source of toxin production. Aggressive IV fluid resuscitation to treat hypotension and shock. Broad-spectrum antibiotics (e.g. clindamycin and penicillin) until specific cultures guide therapy. IV immunoglobulin (IVIG) to neutralize toxins and improve outcomes in severe cases. Supportive care in an ICU, including monitoring for organ dysfunction and complications.
Other Causes	Less commonly, TSS can be caused by other bacterial infections or mixed bacterial flora. Infections following childbirth, abortion, burns, or other invasive procedures.	Identification and removal of the infectious source. Appropriate Antibiotic therapy based on culture results. IV fluid resuscitation and haemodynamic support. Management of AKI, resp failure, or DIC. Close monitoring and support in an ICU setting.

References

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