Toxic shock syndrome

Background

• 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/Criteria

• 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)

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

• 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

Management

• Antibiotics: Clindamycin (suppresses toxin synthesis), plus an anti-staph penicillin (e.g. Oxacillin or Nafcillin) or Vancomycin for MRSA
• Supportive, pressors often needed

Disposition

• Admit