Toxic shock syndrome

Background

Epidemiology

1-2/100,000 cases/yr

Etiology

S. aureus strain that produces toxic shock syndrome toxin-1 (superantigen)

Superantigens stimulate T-cell proliferation independent of antigen-specific binding --> massive cytokine production

Also effect neutrophil chemotaxis suppression, blockage of reticuloendothelial system

Risk Factors

1. postop patients
2. nasal packing
3. abscess
4. burns
5. tampons
6. IUDs

Evaluation

1. Fever: temperature >38.9°C
2. Rash: diffuse macular erythroderma
3. Hypotension: systolic blood pressure <90 mm Hg (adults) or <5th percentile for age (children younger than 16 years), or orthostatic hypotension, dizziness, or syncope
4. Multisystem dysfunction: at least 3:
   1. Gastrointestinal: vomiting or diarrhea at onset of illness
   2. Muscular: severe myalgias, or serum creatine phosphokinase level (CPK) greater than twice the upper limit of normal
   3. Mucous membranes: vaginal, oropharyngeal, or conjunctival hyperemia
   4. 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
   5. Hepatic: total serum bilirubin or transaminase level greater than twice the upper limit of normal
   6. Hematologic: platelets<100,000/L
   7. Central nervous system: disorientation or alteration in consciousness but no focal neurologic signs at a time when fever and hypotension are absent.
5. Desquamation: One to 2 weeks after the onset of illness (typically palms and soles)
6. Evidence against an alternative diagnosis: If obtained:
   1. negative culture results for blood, throat, or cerebrospinal fluid
   2. absence of an increase in antibody titers to the agents of leptospirosis, measles, or Rocky Mountain spotted fever.

^“Confirmed” case meets all 6 criteria; “probable” case meets 5 of the 6.

†Blood culture may be positive for S aureus.

Management

1. Abx, including Clindamycin, Vanc
2. Supportive, pressors often

References

AnnalsofEM Nov 2009