Fever
Toxic Shock Syndrome
search
Toxic Shock Syndrome
Causes
Bacteria
Staphylococcus aureus
Facilitated by staphylococcal toxin (TSS Toxin 1 or Enterotoxin B)
Streptococcus Pyogenes
(
Group A Streptococcus
)
Facilitated by M Protein (antiphagocytic function), exotoxins and endotoxins
S. agalactiae (Group B Strep) and S. Dysgalactiae have also caused Toxic Shock Syndrome
Clostridium
sordellii (
Clostridia
l Toxic Shock Syndrome)
Previously associated with elective
Termination of Pregnancy
(see
Unintended Pregnancy
)
Has also occurred with IUD and with
IV Drug Abuse
Often affebrile with high
Hemoglobin
/hematoctrit and in fatal cases,
Leukemoid Reaction
(WBC >50k)
Treated with
Penicillin
s, carbapenems or
Cephalosporin
s AND
Clindamycin
Requires substantial
Fluid Replacement
due to capillary leak
Aldape (2006) Clin Infect Dis 43(11): 1436-46 +PMID:17083018 [PubMed]
Causes
Staphylococcal TSS Precipitating Factors
Highly absorbent tampons (especially those left in place for days)
Onset of toxic shock within 5 days of
Menses
Responsible for 50% of Staphylococcal Toxic
Shock
cases
Decreasing
Incidence
in the United States (since highly absorbent tampons are off the market)
Barrier Contraceptives
Postoperative
Wound Infection
s (including postpartum), especially wounds that are packed
Burn Injury
and other
Skin Wound
s
Nasal Packing
Osteomyelitis
Causes
Streptococcal TSS Precipitating Factors
Sinusitis
Empyema
Peritonsillar Abscess
Necrotizing Fasciitis
Superinfected
Varicella Zoster Virus
Infection
Risk Factors
Streptococcal TSS
Alcoholism
Diabetes Mellitus
HIV Infection
Symptoms
Influenza
-like illness
Focal symptoms (depending on source)
Nausea
or
Vomiting
Diarrhea
Signs
High
Fever
Rash (
Erythroderma
)
Hypotension
Multisystem organ failure (3 or more)
Palm and Sole Desquamation
(1-2 weeks after symptom onset)
Exam
Evaluate for all possible sources
Pelvic exam for
Retained Foreign Body
in all women
Labs
Complete Blood Count
Thrombocytopenia
Comprehensive Metabolic Panel
Hypocalcemia
Acute Kidney Injury
Urinalysis
and
Urine Culture
Blood Culture
s (with
Gram Stain
)
Lactic Acid
Consider
Lumbar Puncture
Imaging
Chest XRay
May present in
ARDS
Consider CT imaging of suspected source
Differential Diagnosis
See
Septic Shock
See
Undifferentiated Shock
Erythema Multiforme Major
(
Toxic Epidermal Necrolysis
,
Stevens-Johnson Syndrome
)
Kawasaki Disease
Endocarditis
Meningococcemia
Rocky Mountain Spotted Fever
Typhoid Fever
Pneumococcal Pneumonia
Leptospirosis
Heat Stroke
Management
Gene
ral Management
See
Septic Shock
Aggressive supportive care as per
Septic Shock
regimen
IVIG
Indicated in all cases of suspected toxic shock (either staphylococcal or streptococcal)
Dose: 1 g/kg on day 1, then 0.5 g/kg on days 2 and 3
More effective in neutralizing
Streptococcus Pyogenes
toxin, than
Staphylococcus aureus
Staphylococcal Toxic Shock Syndrome Antibiotics
Methicillin
Sensitive (
MSSA
)
Nafcillin
2 g IV q4h or
Oxacillin
2 g IV q4h (or
Cefazolin
1-2 g IV q8h) AND
Clindamycin
900 mg IV every 8 hours (to suppress toxin production)
Methicillin
Resistant (
MRSA
)
Vancomycin
(or
Daptomycin
6 mg/kg IV q24h or
Linezolid
) AND
Clindamycin
900 mg IV every 8 hours (to suppress toxin production)
Streptococcal Toxic Shock Syndrome Antibiotics
Early surgical
Debridement
of
Necrotizing Fasciitis
Primary protocol (preferred)
Penicillin
G AND
Clindamycin
900 mg IV every 8 hours (to suppress toxin production)
Alternative protocol (
Penicillin Allergy
)
Vancomycin
AND
Clindamycin
900 mg IV every 8 hours (to suppress toxin production)
Alternative protocol (other)
Ceftriaxone
AND
Clindamycin
900 mg IV every 8 hours (to suppress toxin production)
Complications
Acute Kidney Injury
Acute Respiratory Distress Syndrome
High mortality rate (esp. Streptococcal toxic shock)
References
Chambers (2015) Toxic Shock Syndrome, Sanford Guide to Antimicrobial Therapy, accessed 4/13/2015
Stevens (2014) Toxic Shock Syndrome, UpToDate, accessed 4/13/2015
Venkataraman (2014) Toxic Shock Syndrome, Medscape EMedicine, accessed 4/13/2015
Lappin (2009) Lancet Infect Dis 9(5): 281-90 +PMID:19393958 [PubMed]
Type your search phrase here