Toxic shock syndrome: Difference between revisions

Revision as of 12:49, 30 July 2016

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

postop patients
nasal packing
abscess
burns
tampons
IUDs

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
- Afebrile
  - Alcohol intoxication
  - Anaphylaxis
  - Cellulitis
  - Dermatitis (multiple types)
  - Drug rash
  - Erysipelas
  - Erythema multiforme
  - Exfoliative erythroderma
  - Scombroid
  - Vancomycin infusion reaction

Evaluation

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)
Evidence against an alternative diagnosis: If obtained:
- negative culture results for blood, throat, or cerebrospinal fluid
- 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

Abx, including Clindamycin, Vanc
Supportive, pressors often

References

AnnalsofEM Nov 2009

Authors:

@@ Line 10: / Line 10: @@
 Also effect neutrophil chemotaxis suppression, blockage of reticuloendothelial system
-==Risk Factors==
+===Risk Factors===
-#postop patients
+*postop patients
-#[[Epistaxis|nasal packing]]
+*[[Epistaxis|nasal packing]]
-#abscess
+*abscess
-#burns
+*burns
-#tampons
+*tampons
-#IUDs
+*IUDs
 ==Differential Diagnosis==
@@ Line 22: / Line 22: @@
 ==Evaluation==
-#Fever: temperature >38.9°C
+*Fever: temperature >38.9°C
-#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
-#Multisystem dysfunction: at least 3:
+*Multisystem dysfunction: at least 3:
-##Gastrointestinal: vomiting or diarrhea at onset of illness
+**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
+**Muscular: severe myalgias, or serum creatine phosphokinase level (CPK) greater than twice the upper limit of normal
-##Mucous membranes: vaginal, oropharyngeal, or conjunctival hyperemia
+**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
+**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
+**Hepatic: total serum bilirubin or transaminase level greater than twice the upper limit of normal
-##Hematologic: platelets<100,000/L
+**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.
+**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)
-#Evidence against an alternative diagnosis: If obtained:
+*Evidence against an alternative diagnosis: If obtained:
-##negative culture results for blood, throat, or cerebrospinal fluid
+**negative culture results for blood, throat, or cerebrospinal fluid
-##absence of an increase in antibody titers to the agents of leptospirosis, measles, or Rocky Mountain spotted fever.
+**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.
@@ Line 43: / Line 43: @@
 ==Management==
-#Abx, including Clindamycin, Vanc
+*Abx, including Clindamycin, Vanc
-#Supportive, pressors often
+*Supportive, pressors often
 ==References==