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toxic shock syndrome

Etiology: 1) Staphylococcus aureus a) epidemic of cases in menstruating women in early 1980s due to use of 'super-abdorbent' tampons b) post operative patients, esp ENT cases with nasal packs c) abscesses, gauze-packed wounds d) skin ulcers, burns, catheters, injection drug use [1] 2) group A beta-hemolytic Streptococci - associated with necrotizing fasciitis Epidemiology: 1) young adults (age 15-34) most commonly affected 2) women comprise 85% of cases Pathology: 1) Staphylococcus aureus strains that produce: a) toxic shock exotoxin TSST-1 (20% of S aureus strains), or b) enterotoxins B or C 2) Streptococcal form of toxic shock syndrome (group A) a) pyrogenic exotoxin A b) certain M types Clinical manifestations: 1) fever > 38.9 C (102.2 F, 39.8 C) 2) hypotension, < 90 mm Hg systolic 3) skin manifestations a) localized or diffuse erythema 'sunburn rash' macular rash followed by peripheral desquamation in 5-14 days b) palms & soles affected [1] c) affected skin has a rough 'sandpaper' texture 4) see Diagnostic criteria Diagnostic criteria: (CDC) 1) Staphylococcal toxic shock syndrome a) fever (T > 102 F, 39.8 C) b) hypotension - systolic BP < 90 mm Hg - orthostatic fall in diastolic BP > 14 mm Hg - symptoms of orthostatic hypotension c) rash - diffuse macular erythroderma, especially palms & soles [1] d) desquamation - occurs 1-2 weeks after onset of symptoms - especially on palms & soles e) involvement of 3 or more of the following organ systems - GI: nausea, vomiting, diarrhea - muscular: severe myalgias or serum creatine kinase (CK) > 5-fold upper limit of normal - mucous membranes: hyperemia of vagina, pharynx, conjunctiva - often best seen in conjunctiva - renal: creatinine or BUN > 2-fold upper limit of normal or urinalysis with > 5 WBC/hpf - hepatic: serum transaminases or serum bilirubin > 2-fold upper limit of normal - hematologic: platelet count < 100,000/mm3 - CNS: altered mental status while afebrile (non-focal exam) f) negative results on the following tests (if performed) a) blood, throat & CSF cultures (blood culture may be positive for Staphylococcus aureus) b) negative serology for Rocky Mountain spotted fever, Leptospirosis or rubeola (measles) c) CSF cultures - may grow Staphyloccus aureus - negative for other organisms 2) Streptococcal toxic shock syndrome a) isolation of group-A beta-hemolytic Streptococci from a normally sterile site (definite case) b) isolation of group-A beta-hemolytic Streptococci from a non-sterile site (probable case) c) hypotension, systolic BP < 90 mm Hg c) 2 or more of the following - acute renal failure - elevated serum transaminases - erythematous macular rash with soft tissue necrosis - necrotizing fasciitis - coagulopathy: thrombocytopenia, DIC - pulmonary: ARDS Differential diagnosis: - Staphylococcal scalded skin syndrome Management: 1) fluid resuscitation a) may need massive volumes b) 10-20 L IV fluids 2) albumin replacement 3) vasopressor support to maintain blood pressure - norepinephrine drip as needed 4) identify & remove source of infection & toxin - tampon, nasal packing, abscess - surgical debridement often needed [1] 5) contact isolation until completion of 24 hours of antibiotic therapy 6) empiric broad spectrum antibiotics until organism is identified [1] - vancomycin or linezolid + meropenem + clindamycin - meropenem for gram-negative coverage - clindamycin for anaerobe & Streptococcal coverage 7) anti-Staphylococcus antibiotics do not alter the course of the disease, but do reduce recurrence rate a) nafcillin & clindamycin b) vancomycin or linezolid + clindamycin for MRSA 8) Streptococcal toxic shock syndrome - penicillin & clindamycin [1] 9) no role for corticosteroids or immune globulin [1] Prognosis: 1) overall mortality 2-5% (higher in non-menstrual cases) 2) recurrence rate of 30% - recurrent episodes less severe

General

bacterial infection skin disease (dermatologic disorder, dermatopathy, dermatosis)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 93