Toxic shock syndrome

Background

• Staphylococcal (Staph aureus) and Streptococcal (Type A strep: Step. pyogenes) types
• 1-2/100,000 cases/year
• S. aureus strain that produces toxic shock syndrome toxin-1 (superantigen) is the most common cause
  • GAS is a less common cause
• Superantigens stimulate T-cell proliferation independent of antigen-specific binding → massive cytokine production
  • Also affect neutrophil chemotaxis suppression and blockage of reticuloendothelial system

Risk Factors

• Postop patients
• Nasal packing
• Abscess
• Burns
• Tampon use
• IUDs

Clinical Features

Clinical Criteria Staphylococcal toxic shock

Skin desquamation

• Fever: temperature >38.9°C
• Rash: diffuse macular erythroderma
• Hypotension: systolic blood pressure <90 mm Hg (adults) or <5th percentile for age (children younger than 16 years), or orthostatic hypotension, dizziness, or syncope
• Multisystem dysfunction: at least 3:
  • Gastrointestinal: vomiting or diarrhea at onset of illness
  • Muscular: severe myalgias, or serum creatine phosphokinase level (CPK) greater than twice the upper limit of normal
  • Mucous membranes: vaginal, oropharyngeal, or conjunctival hyperemia
  • Renal: blood urea nitrogen or creatinine level greater than twice the upper limit of normal, or pyuria (5 leukocytes per high-power field), in the absence of urinary tract infection
  • Hepatic: total serum bilirubin or transaminase level greater than twice the upper limit of normal
  • Hematologic: platelets <100,000/L
  • Central nervous system: disorientation or alteration in consciousness but no focal neurologic signs at a time when fever and hypotension are absent.
• Desquamation: One to 2 weeks after the onset of illness (typically palms and soles)

Clinical Criteria Streptococcal Toxic Shock

• Hypotension: systolic blood pressure <90 (adult) or <5th percentile for age (children younger than 16 years)
• Multiorgan involvement(>2 organ systems):
  • Skin: generalized erythematous macular rash that may desquamate
  • Soft tissue necrosis, including necrotizing fascitis or myositis, or gangrene
  • Acute respiratory distress syndrome: acute onset of diffuse pulmonary infiltrates and hypoxemia in absence of cardiac failure or by evidence of diffuse capillary leak by acute onset of generalized edema, or pleural or peritoneal effusions with hypoalbuminemia.
  • Hepatic: total bilirubin, ALT, or AST >2 times the upper limit of normal for the patient's age. x2 elevation in patients with per-existing liver disease.
  • Renal: serum creatinine >2 milligrams/dL( >177umol/L) for adults or >2 times the upper limit of normal for age. x2 fold increase in creatitine elevation from baseline
  • Coagulopathy: platelet count <100,000/mm3 or DIC.

Differential Diagnosis

Erythematous rash

• Positive Nikolsky’s sign
  • Febrile
    • Staphylococcal scalded skin syndrome (children)
    • Toxic epidermal necrolysis/SJS (adults)
  • Afebrile
    • Toxic epidermal necrolysis
• Negative Nikolsky’s sign
  • Febrile
    • Toxic shock syndrome
    • Kawasaki disease
    • Scarlet fever
    • DRESS syndrome
    • Cellulitis
    • Acute generalized exanthematous pustulosis
  • Afebrile
    • Alcohol intoxication
    • Anaphylaxis
    • Cellulitis
    • Dermatitis (multiple types)
    • Drug rash
    • Erysipelas
    • Erythema multiforme
    • Exfoliative erythroderma
    • Scombroid
    • Vancomycin infusion reaction

Evaluation

Case definition for Staphylococcal Toxic Shock Syndrome

• Lab Criteria for Diagnosis (if obtained):
  • Negative culture results for blood, or cerebrospinal fluid (blood may be positive for S. aureus)
  • Absence of an increase in antibody titers to the agents of leptospirosis, measles, or Rocky mountain spotted fever.
• Confirmed case meets all 5 clinical criteria (clinical features) plus lab criteria
• Probable case meets 4-5 clinical criteria plus lab criteria

Case definition for Streptococcal Toxic Shock Syndrome[2]

• Lab Criteria
  • Isolation of group A Streptoccocus

Case classification:

• Confirmed: All clinical criteria met + all lab criteria met in sterile collection
• Probable: All clinical criteria met + all lab criteria met in non sterile collection of specimen/absence of other identified etiology

Management

• Antibiotics:
  • Staphylococcal: Clindamycin (suppresses toxin synthesis), plus an anti-staph penicillin (e.g. Oxacillin or Nafcillin) or Vancomycin/Linezolid for MRSA
  • Streptococcal: Clindamycin and Piperacillin-tazobactam or Meropenem

• Supportive care, pressors often needed

Disposition

• Admit

External Links

• Internet Bock of Critical Care Toxic Shock Syndrome. https://emcrit.org/ibcc/tss/