Toxic shock syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Staphylococcal(Staph aureus) and Streptococcal(Type A strep: Step. pyogenes) types | *Staphylococcal ([[Staph aureus]]) and Streptococcal ([[Type A strep]]: Step. pyogenes) types | ||
*1-2/100,000 cases/year | *1-2/100,000 cases/year | ||
*[[S. aureus]] strain that produces toxic shock syndrome toxin-1 (superantigen) is the most common cause | *[[S. aureus]] strain that produces toxic shock syndrome toxin-1 (superantigen) is the most common cause | ||
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===Risk Factors=== | ===Risk Factors=== | ||
*Postop patients | *Postop patients | ||
*[[Epistaxis| | *[[Epistaxis|Nasal packing]] | ||
*[[Abscess]] | *[[Abscess]] | ||
*[[Burns]] | *[[Burns]] | ||
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*IUDs | *IUDs | ||
==Clinical Features | ==Clinical Features== | ||
===Clinical Criteria Staphylococcal toxic shock=== | |||
[[File:PMC5423323 gr2.png|thumb|Skin desquamation]] | |||
*[[Fever]]: temperature >38.9°C<ref name="CDC">CDC. Toxic Shock Syndrome (Other Than Streptococcal). 2011</ref> | |||
*[[Rash]]: diffuse macular erythroderma | *[[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 | *[[Hypotension]]: systolic blood pressure <90 mm Hg (adults) or <5th percentile for age (children younger than 16 years), or orthostatic hypotension, dizziness, or syncope | ||
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**Central nervous system: disorientation or alteration in consciousness but no focal neurologic signs at a time when fever and hypotension are absent. | **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) | *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)<ref>Liang SY. Toxic Shock Syndromes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658§ionid=109435589. Accessed November 29, 2017.</ref> | |||
*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== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
Case definition for Staphylococcal Toxic Shock Syndrome | |||
*Lab Criteria for Diagnosis (if obtained)<ref name="CDC"></ref>: | *Lab Criteria for Diagnosis (if obtained)<ref name="CDC"></ref>: | ||
**Negative culture results for blood, or cerebrospinal fluid (blood may be positive for S. aureus) | **Negative culture results for blood, or cerebrospinal fluid (blood may be positive for S. aureus) | ||
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*Confirmed case meets all 5 clinical criteria ([[Toxic_shock_syndrome#Clinical_Features.5B1.5D|clinical features]]) plus lab criteria | *Confirmed case meets all 5 clinical criteria ([[Toxic_shock_syndrome#Clinical_Features.5B1.5D|clinical features]]) plus lab criteria | ||
*Probable case meets 4-5 clinical criteria 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== | ==Management== | ||
*Antibiotics: [[Clindamycin]] (suppresses toxin synthesis), plus an anti-staph penicillin (e.g. [[Oxacillin]] or [[Nafcillin]]) or [[Vancomycin]]/Linezolid for MRSA | *Antibiotics: | ||
*Supportive, [[pressors]] often needed | **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== | ==Disposition== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] | ||
Revision as of 15:09, 16 November 2019
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
- Fever: temperature >38.9°C[1]
- 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)[2]
- 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
- Febrile
- Negative Nikolsky’s sign
- Febrile
- Afebrile
Evaluation
Case definition for Staphylococcal Toxic Shock Syndrome
- Lab Criteria for Diagnosis (if obtained)[1]:
- 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
References
- ↑ 1.0 1.1 CDC. Toxic Shock Syndrome (Other Than Streptococcal). 2011
- ↑ Liang SY. Toxic Shock Syndromes. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658§ionid=109435589. Accessed November 29, 2017.