II. Causes: Bacteria

  1. Staphylococcus aureus
    1. Facilitated by staphylococcal toxin (TSS Toxin 1 or Enterotoxin B)
  2. Streptococcus Pyogenes (Group A Streptococcus)
    1. Facilitated by M Protein (antiphagocytic function), exotoxins and endotoxins
    2. 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

V. Risk Factors: Streptococcal TSS

VI. Symptoms

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

VII. Signs

  1. High Fever
  2. Rash (Erythroderma)
  3. Hypotension
  4. Multisystem organ failure (3 or more)
  5. Palm and Sole Desquamation (1-2 weeks after symptom onset)

VIII. Exam

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

X. Imaging

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

XII. Management

  1. General Management
    1. See Septic Shock
    2. Aggressive supportive care as per Septic Shock regimen
    3. 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
  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)

XIII. Complications

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

XIV. 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. Lappin (2009) Lancet Infect Dis 9(5): 281-90 +PMID:19393958 [PubMed]

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Related Studies

Ontology: Toxic Shock Syndrome (C0600327)

Definition (CHV) a fatal disease caused by an infection
Definition (CHV) a fatal disease caused by an infection
Definition (CHV) a fatal disease caused by an infection
Definition (CHV) a fatal disease caused by an infection
Definition (NCI_FDA) A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting, diarrhea, and myalgia, followed by hypotension and in severe cases, shock; a sunburn-like rash with peeling of the skin, especially of the palms and soles, occurs during the acute phase.
Definition (NCI) A rare acute life-threatening systemic bacterial noncontagious illness caused by any of several related staphylococcal exotoxins. TSS characterized by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. Laboratory findings consistent with TSS include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria.
Definition (CSP) syndrome characterized by high fever, vomiting, diarrhea, confusion, and skin rash; almost all cases have been related to an infection with toxin-producing Staphylococcus aureus.
Concepts Disease or Syndrome (T047)
MSH D012772
ICD9 040.82
ICD10 A48.3
SnomedCT 18504008
English Shock Syndrome, Toxic, Shock Syndromes, Toxic, Syndrome, Toxic Shock, Syndromes, Toxic Shock, Toxic Shock, Toxic Shock Syndromes, TSS, toxic shock, SHOCK TOX, TOX SHOCK SYNDROME, toxic shock syndrome (diagnosis), toxic shock syndrome, Syndrome toxic shock, Toxic shock syndrome NOS, toxic shock syndrome (TSS), tss, toxic-shock syndrome, Toxic Shock Syndrome, Toxic shock syndrome, TSS - Toxic shock syndrome, Toxic shock syndrome (disorder), shock syndrome; toxic, shock; toxic (syndrome), syndrome; toxic shock, toxic; shock syndrome, toxic; shock, Shock, Toxic
Italian Sindrome da shock tossico, Sindrome da shock tossico NAS, Shock tossico, Syndrome da shock tossico
Dutch toxische shock syndroom NAO, syndroom toxische shock, shock; toxisch (syndroom), shocksyndroom; toxisch, syndroom; toxische shock, toxisch; shocksyndroom, toxisch; shock, toxische shock syndroom, Shock, toxische, Toxische-shocksyndroom
French Syndrome de choc toxique SAI, Syndrome du choc toxique, Syndrome de choc toxique staphylococcique, Syndrome de choc toxique
German toxisches Schocksyndrom NNB, Toxischer Schock, Toxic-Schock-Syndrom, Toxic-Shock-Syndrome, Toxisches Schocksyndrom, Schock, toxischer, Syndrom des toxischen Schocks, toxisches Schock-Syndrom, Toxisches Schock-Syndrom
Portuguese Síndrome de choque tóxico, Síndrome de choque tóxico NE, Choque Tóxico, Síndroma de choque tóxico, Síndrome do Choque Tóxico
Spanish Síndrome del shock tóxico NEOM, Síndrome del Choque Tóxico, Choque Tóxico, TSS, síndrome del shock tóxico (trastorno), síndrome del shock tóxico, Síndrome del shock tóxico
Japanese 中毒性ショック症候群NOS, 中毒性ショック症候群, チュウドクセイショックショウコウグン, チュウドクセイショックショウコウグンNOS
Czech Syndrom toxického šoku, Syndrom toxického šoku NOS, toxický šok, syndrom toxického šoku, šok toxický
Korean 포도알균독성 쇼크 증후군
Hungarian toxikus shock syndroma k.m.n., toxikus shock syndroma, toxicus shock syndroma
Norwegian Toksisk sjokk-syndrom, Toksisk sjokk, Tampong-sjokk-syndromet, Sjokk, toksisk, Toksisk sjokksyndrom