Streptococcal Toxic Shock Syndrome (TSS)


  • Distribution of Etiologies: Streptococcus-associated toxic shock syndrome is more commonly associated with skin or soft tissue infection (including necrotizing fasciitis, myositis, gangrene, and/or cellulitis) than Staphylococcus-associated toxic shock syndrome


  • Streptococcus Pyogenes (Group A Streptococcus) (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]])
    • May be associated with elaboration of pyrogenic exotoxin A (although this is controversial): toxin may act as a superantigen, causing T-cell release of inflammatory cytokines


Skin/Soft Tissue Infection

Other Infections


  • Blood Culture/Sensitivity: bacteremia is more common in Streptococcus-associated toxic shock syndrome than in Staphylococcus-associated toxic shock syndrome
  • Wound Culture/Sensitivity: may be positive

Diagnostic Criteria [MEDLINE]

  • Isolation of Streptococcus Pyogenes
    • From Normally Sterile Site
    • From Non-Sterile Site
  • Clinical Signs of Severity
    • Hypotension (see Hypotension, [[Hypotension]])
    • At Least Two of the Following
      • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]])
      • Coagulopathy (see Coagulopathy, [[Coagulopathy]])
      • Elevated Liver Function Tests (LFT’s) (see xxxx, [[xxxx]])
      • Adult Respiratory Distress Syndrome (ARDS) (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
      • Generalized Erythematous Macular Rash (Which May Desquamate) (see Erythroderma, [[Erythroderma]])
      • Soft Tissue Necrosis: necrotizing fasciitis, myositis, and/or gangrene

Clinical Manifestations

Cardiovascular Adverse Effects

Dermatologic Manifestations

  • Erythrodermatous Rash (see Erythroderma, [[Erythroderma]] and Exanthems, [[Exanthems]]): may desquamate

Hematalogic Manifestations

  • Leukocytosis (see Leukocytosis, [[Leukocytosis]])
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]]): typically becomes more prominent on the 2nd-3rd day of the illness

Pulmonary Manifestations

  • Acute Lung Injury (ALI)/Adult Respiratory Distress Syndrome (ARDS) (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])

Other Manifestations



  • Indicated

Treat Local Sites of Streptococcus Infection (Source Control)

  • Surgical Wound Debridement: indicated for necrotizing fasciitis

Supportive Care

  • Management of Sepsis (see Sepsis, [[Sepsis]]): fluids, pressors, etc
  • Mechanical Ventilation (see General Ventilator Management, [[General Ventilator Management]]): as required


  • Mortality: over 30% (most deaths occur due to shock and/or respiratory failure)


  • Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections. JAMA. 1993 Jan 20;269(3):390-1 [MEDLINE]