Toxic Shock Syndrome

Aka: Toxic Shock Syndrome

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II. Causes: Bacteria

  1. Staphylococcus aureus
    1. Facilitated by staphylococcal toxin (TSS Toxin 1 or Enterotoxin B)
    2. More common in age <40 years
  2. Streptococcus Pyogenes (Group A Streptococcus)
    1. Most common cause of toxic shock and affects all ages
    2. Facilitated by M Protein (antiphagocytic function), exotoxins and Endotoxins
    3. S. agalactiae (Group B Strep) and S. Dysgalactiae have also caused Toxic Shock Syndrome
  3. Clostridium sordellii (Clostridial Toxic Shock Syndrome)
    1. Previously associated with elective Termination of Pregnancy (see Unintended Pregnancy)
    2. Has also occurred with IUD and with IV Drug Abuse
    3. Often affebrile with high Hemoglobin/hematoctrit and in fatal cases, Leukemoid Reaction (WBC >50k)
    4. Treated with Penicillins, Carbapenems or Cephalosporins AND Clindamycin
    5. Requires substantial Fluid Replacement due to capillary leak
    6. Aldape (2006) Clin Infect Dis 43(11): 1436-46 +PMID:17083018 [PubMed]

III. Causes: Staphylococcal TSS Precipitating Factors

  1. Highly absorbent tampons (especially those left in place for days)
    1. Onset of toxic shock within 5 days of Menses
    2. Responsible for 50% of Staphylococcal Toxic Shock cases
      1. Decreasing Incidence in the United States (since highly absorbent tampons are off the market)
  2. Barrier Contraceptives
  3. Postoperative Wound Infections (including postpartum), especially wounds that are packed
  4. Burn Injury and other Skin Wounds
  5. Nasal Packing
  6. Osteomyelitis

IV. Causes: Streptococcal TSS Precipitating Factors

  1. Upper Respiratory Infection (Acute Sinusitis, Acute Pharyngitis)
  2. Empyema or Pneumonia
  3. Peritonsillar Abscess
  4. Necrotizing Fasciitis or Cellulitis
  5. Superinfected Varicella Zoster Virus Infection

V. Risk Factors

  1. General
    1. Pregnancy increases toxic shock risk by 20 fold
  2. Streptococcal TSS
    1. Alcoholism
    2. Diabetes Mellitus
    3. HIV Infection

VI. Findings: Common Presentations of an Uncommon Disease

  1. Diffuse Sunburn-like rash with fever and ill appearance
  2. Streptococcus or Staphylococcus infection with Sepsis or hemodynamic instability
  3. Signs of Sepsis with underwhelming infection source findings (e.g. minor Cellulitis, Gastroenteritis)
  4. Pregnant or postpartum patient following an obstetric procedure

VII. Symptoms: General

  1. Influenza-like illness
  2. Focal symptoms (depending on source)
  3. Nausea or Vomiting
  4. Diarrhea

VIII. Signs

  1. High Fever
  2. Rash (Erythroderma)
    1. Sunburn-like rash that be subtle or transient
  3. Hypotension
  4. Multisystem organ failure (3 or more)
  5. Palm and Sole Desquamation
    1. Late finding, occurring 1-2 weeks after symptom onset

IX. Exam

  1. Evaluate for all possible sources
  2. Pelvic exam for Retained Foreign Body in all women

X. Labs

  1. Complete Blood Count
    1. Thrombocytopenia
  2. Comprehensive Metabolic Panel
    1. Hypocalcemia
    2. Acute Kidney Injury (may be the first affected organ)
  3. Urinalysis and Urine Culture
  4. Blood Cultures (with Gram Stain)
    1. Positive in 60% of Streptococcus cases, but <5% of Staphylococcus cases
  5. Lactic Acid
  6. Consider Lumbar Puncture

XI. Imaging

  1. Chest XRay
    1. May present in ARDS
  2. Consider CT imaging of suspected source

XII. Differential Diagnosis

  1. See Septic Shock
  2. See Undifferentiated Shock
  3. Erythema Multiforme Major (Toxic Epidermal Necrolysis, Stevens-Johnson Syndrome)
  4. Kawasaki Disease
  5. Endocarditis
  6. Meningococcemia
  7. Rocky Mountain Spotted Fever
  8. Typhoid Fever
  9. Pneumococcal Pneumonia
  10. Leptospirosis
  11. Heat Stroke

XIII. Management

  1. General Management
    1. See Septic Shock
    2. Aggressive supportive care as per Septic Shock regimen
    3. Rapidly start fluid Resuscitation and Antibiotics
  2. Staphylococcal Toxic Shock Syndrome Antibiotics
    1. Methicillin Sensitive (MSSA)
      1. Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h (or Cefazolin 1-2 g IV q8h) AND
      2. Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
    2. Methicillin Resistant (MRSA)
      1. Vancomycin (or Daptomycin 6 mg/kg IV q24h or Linezolid) AND
      2. Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
  3. Streptococcal Toxic Shock Syndrome Antibiotics
    1. Early surgical Debridement of Necrotizing Fasciitis
    2. Primary protocol (preferred)
      1. Penicillin G AND
      2. Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
    3. Alternative protocol (Penicillin Allergy)
      1. Vancomycin AND
      2. Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
    4. Alternative protocol (other)
      1. Ceftriaxone AND
      2. Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
  4. Other measures
    1. IVIG
      1. Indicated in all cases of suspected toxic shock (either staphylococcal or streptococcal)
      2. Dose: 1 g/kg on day 1, then 0.5 g/kg on days 2 and 3
      3. More effective in neutralizing Streptococcus Pyogenes toxin, than Staphylococcus aureus
      4. Overall, expensive intervention with underwhelming efficacy
    2. Plasmapheresis
      1. NOT effective in trials

XIV. Complications

  1. Acute Kidney Injury
  2. Acute Respiratory Distress Syndrome
  3. High mortality rate (esp. Streptococcal toxic shock)

XV. References

  1. Chambers (2015) Toxic Shock Syndrome, Sanford Guide to Antimicrobial Therapy, accessed 4/13/2015
  2. Stevens (2014) Toxic Shock Syndrome, UpToDate, accessed 4/13/2015
  3. Venkataraman (2014) Toxic Shock Syndrome, Medscape EMedicine, accessed 4/13/2015
  4. Werner and Long (2023) Toxic Shock Syndrome, EM:Rap, accessed 8/1/2023
  5. Lappin (2009) Lancet Infect Dis 9(5): 281-90 +PMID:19393958 [PubMed]

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