Fever

Toxic Shock Syndrome

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Toxic Shock Syndrome

  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]
  • 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
  • Causes
  • Streptococcal TSS Precipitating Factors
  1. Sinusitis
  2. Empyema
  3. Peritonsillar Abscess
  4. Necrotizing Fasciitis
  5. Superinfected Varicella Zoster Virus Infection
  • Risk Factors
  • Streptococcal TSS
  1. Alcoholism
  2. Diabetes Mellitus
  3. HIV Infection
  • Symptoms
  1. Influenza-like illness
  2. Focal symptoms (depending on source)
  3. Nausea or Vomiting
  4. Diarrhea
  • 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)
  • Exam
  1. Evaluate for all possible sources
  2. Pelvic exam for Retained Foreign Body in all women
  • Labs
  1. Complete Blood Count
    1. Thrombocytopenia
  2. Comprehensive Metabolic Panel
    1. Hypocalcemia
    2. Acute Kidney Injury
  3. Urinalysis and Urine Culture
  4. Blood Cultures (with Gram Stain)
  5. Lactic Acid
  6. Consider Lumbar Puncture
  • Imaging
  1. Chest XRay
    1. May present in ARDS
  2. Consider CT imaging of suspected source
  • 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
  • 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)
  • Complications
  1. Acute Kidney Injury
  2. Acute Respiratory Distress Syndrome
  3. High mortality rate (esp. Streptococcal toxic shock)
  • 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]