Epidemiology

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Microbiology

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Exposure

Menstrual/Vaginal/Reproductive Exposure

• Barrier Contraceptive Use
• Post-Partum C-Section Wound Infection
• Post-Partum Vaginal Infection
• Tampon Use

Non-Menstrual Exposure

Dermatologic Infection

• Cellulitis (see Cellulitis)
• Dermatitis
  • Contact Dermatitis (see Contact Dermatitis-Irritant and Contact Dermatitis-Allergic)
• Erysipelas (Erysipelas)
• Insect/Animal Bite
• Intravenous (IV) Site
• Skin Abrasion

Foreign-Body Insertion

• Augmentation Mammoplasty
• Orthopedic Prosthesis
• Peritoneal Dialysis (PD) (see Peritoneal Dialysis)
• Post-Operative Wound Infection: typically occurs on post-operative day #2
• Sutures

Mucous-Membrane Injury

• Acute Rhinosinusitis (see Acute Rhinosinusitis)
• Croup (see Croup)
• Dental Abscess (see Dental Abscess)
• Influenza (see Influenza Virus)
• Nasal Packing
• Peritonitis (see Peritonitis)

Deep Tissue Infection

• Abscess
  • Abdominal Abscess (see Abdominal Abscess)
• Empyema (see Pleural Effusion-Exudate)
• Endocarditis (see Endocarditis)
• Osteomyelitis (see Osteomyelitis)
• Pneumonia (see Pneumonia)

Other

• Primary Staphylococcal Bacteremia
  • Uncommon etiology of toxic shock syndrome

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Diagnosis

Blood Culture (see Blood Culture)

• Blood Cultures are Usually Negative
• Vaginal Culture/Sensitivity (see xxxxx)
• may be positive for Staphylococcus Aureus
  • Vaginal colonization (rather than overt infection) is usually present

Wound Culture/Sensitivity

• may be positive for *Staphylococcus Aureus
  • Colonization (rather than overt wound infection) is usually present

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Diagnostic Criteria (MMWR Recomm Rep, 1990) [MEDLINE]

• Fever (see Fever): T >38.9 C
• Hypotension (see Hypotension, [[Hypotension]]): SBP <90 mm Hg or orthostatic hypotension (drop >15 mm Hg, orthostatic syncpe, orthostatic dizziness)
• Diffuse Macular Rash (Incuding Palms and Soles) with Desquamation 1-2 Weeks After Onset (see Erythroderma)
  • Mucosal Membrane Hyperemia
    • Conjunctival Mucosal Membrane Hyperemia
    • Oropharyngeal Mucosal Membrane Hyperemia
    • Vaginal Mucosal Membrane Hyperemia
• Multisystem Involvement
  • Altered Mental Status/Delirium (see Delirium): in absence of fever or hypotension
  • Azotemia (see Azotemia): Cr >2x upper limit of normal
  • Diarrhea (see Diarrhea)
  • Elevated Creatine Kinase (CK) (see Rhabdomyolysis): >2x upper limit of normal
  • Elevated Liver Function Tests (LFT’s) (see Elevated Liver Function Tests): total bili or transaminases >2x normal
  • Myalgias (see Myalgias)
  • Thrombocytopenia (see Thrombocytopenia): <100k
  • Vomiting (see Nausea and Vomiting)
• Negative Serology for Other Diagnoses: including for Measles, Leptospirosis, and Rocky Mountain Spotted Fever
• Negative Blood and Cerebrospinal Fluid (CSF) Cultures: for organisms other than Staph Aureus

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Clinical Manifestations

Disease Timing

• Onset: typically acute
• Relationship of Onset in Menstrual cases to Menstruation: typically begin 2-3 days after start of menstruation

Dermal Manifestations

• Scarlatiniform Rash/Erythroderma (“Sunburn-Like” Rash) (see Erythroderma and Exanthems)
  • Epidemiology
    • Scarlatiniform Rash/Erythroderma Occurs in Approximately 10% of Streptococcal Toxic Shock Cases (JAMA, 1993) [MEDLINE]
    • XXXXXXX
  • Clinical
    • Rash Particularly Involves the Palms and Soles (But Also Involves the Face, Trunk, and Extremities)
    • Rash May Be Subtle and Patchy
    • Hyperemia of Mucous Membranes
      • Hyperemia of Orpharyngeal Mucous Membranes
      • Hyperemia of Conjunctival Mucous Membranes
      • Hyperemia of Vaginal Mucous Mucous Membranes: often with discharge
    • Hyperemia of Wound Site: typically without overt wound infection
    • Erythroderma is more common in Staphylococcus-associated toxic shock syndrome cases than in Streptococcus-associated toxic shock syndrome cases
  • Prognosis
    • Rash Typically Desquamates Over the Subsequent 1-2 wks

Gastrointestinal Manifestations

• Abdominal Pain (see Abdominal Pain)
• Diarrhea (see Diarrhea): common
• Elevated LFT’s (see xxxx)
  • Elevated Bilirubin
  • Transaminitis
• Vomiting (see Nausea and Vomiting)

Hematologic Manifestations

• Leukocytosis (see Leukocytosis)
• Thrombocytopenia (see Thrombocytopenia)

Other Manifestations

• Acute Kidney Injury (AKI) (see Acute Kidney Injury)
  • May occur early and precede onset of hypotension (which may distinguish toxic shock syndrome from other sepsis syndromes
• Delirium/Altered Mental Status (see Delirium)
  • Lumbar Puncture: normal
• Fever (see Fever)
• Hypoalbuminemia (see Hypoalbuminemia)
• Hypocalcemia (see Hypocalcemia)
• Hypotension/Orthostasis (see Hypotension): typically develops within hours of onset of symptoms
• Myalgias (see Myalgias)
• Rhabdomyolysis (see Rhabdomyolysis)
  • Elevated Creatine Kinase (CK)

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Prevention

• Avoidance of Long-Term Tampon Use

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Treatment

Antibiotics

• General Comments: role in treatment is unclear, but likely beneficial to reduce organism carriage and inhibit toxin synthesis
• Nafcillin or Oxacillin + Clindamycin (see Nafcillin, Oxacillin, [[Oxacillin]]), and Clindamycin): if only methicillin-susceptible Staphylococcus Aureus (MSSA) is suspected
  • Clindamycin is a protein synthesis inhibitor which decreases in vitro toxin synthesis
• Vancomycin + Clindamycin (see Vancomycin and Clindamycin, [[Clindamycin]]): if methicillin-resistant Staphylococcus Aureus (MRSA) is suspected
  • Clindamycin is a protein synthesis inhibitor which decreases in vitro toxin synthesis
• Linezolid (Zyvox) (see Linezolid): also decreases in vitro toxin synthesis

Intravenous Immunoglobulin (IVIG) (see Intravenous Immunoglobulin, [[Intravenous Immunoglobulin]])

• Adjunctive Treatment: blocks the effect of the toxin
  • No randomized trials, but improved mortality in case series

Treat Local Sites of Infection (Source Control)

• Remove Infected Source: if possible

Supportive Care

• Management of Sepsis (see Sepsis): as required
  • Intravenous Fluids
  • Vasopressors
• Mechanical Ventilation (see General Ventilator Management, [[General Ventilator Management]]): as required

Corticosteroids (see Corticosteroids)

• No Clear Role

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Prognosis

• Mortality: usually due to ARDS, hypotension, and/or DIC
  • Menstrual-Associated TSS: 5% mortality
  • Non-Menstrual-Associated TSS: 10-15% mortality
  • Streptococcal TSS: 30-70% mortality
• Recurrence: up to 30% of affected menstruating females may have recurrence (although milder) with future menses
  • Recurrence only occurs in those with lack the anti-TSST-1 antibody

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References

General

• Case definitions for public health surveillance. MMWR Recomm Rep. 1990 Oct 19;39(RR-13):1-43 [MEDLINE]
• Toxic shock syndrome: broadening the differential diagnosis. J Am Board Fam Pract. 2001 Mar-Apr;14(2):131-6 [MEDLINE]
• Staphylococcal toxic shock syndrome. Suspicion and prevention are keys to control. Postgrad Med. 2001 Oct;110(4):55-6, 59-62 [MEDLINE]

Diagnosis

• XXXX

Clinical

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

Treatment

• Intravenous immunoglobulin for treating sepsis and septic shock. Cochrane Database Syst Rev. 2002(1):CD001090 [MEDLINE]