Toxic shock syndrome

Background

Epidemiology

1-2/100,000 cases/year

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
    • 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

• 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