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

Clinical Features

  • 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

Evaluation

^“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

Disposition

References

AnnalsofEM Nov 2009