Toxic Shock Syndrome

Key Features

• Multiple organisms that can cause toxic shock syndrome (TSS) include

  • Staphylococcus aureus

  • Streptococcus

  • Certain Clostridium species (C perfringens, C sordellii)

Staphylococcus aureus

• Strains of staphylococci may produce toxins that can cause three important entities

  • Scalded skin syndrome, typically in children, or bullous impetigo in adults

  • TSS

  • Enterotoxin food poisoning

• Although originally associated with tampon use, any focus (eg, nasopharynx, bone, vagina, rectum, abscess, or wound) harboring a toxin-producing S aureus strain can cause TSS

• Fatality rates may be as high as 15%

Streptococcal infection

• Any streptococcal infection—and necrotizing fasciitis in particular—can cause TSS

• TSS is due to pyrogenic erythrotoxin, a superantigen that stimulates massive release of inflammatory cytokines believed to mediate the shock

• Invasive disease

  • Risk factors are age (very young or older persons) and underlying medical conditions

  • Bacteremia occurs in most cases

• Mortality rates can be up to 80%

Clostridium sordellii

• C sordellii is a rare cause of endometritis and TSS following childbirth

• Fatal cases of uterine infection following medically induced abortion with mifepristone have been reported

Clinical Findings

S aureus

• Toxic shock is characterized by abrupt onset of high fever, vomiting, and watery diarrhea

• Sore throat, myalgias, and headache are common

• A diffuse macular erythematous rash and nonpurulent conjunctivitis are common, and desquamation, especially of the palms and soles, is typical during recovery

Streptococcal TSS

• Invasion of skin or soft tissues

• Acute respiratory distress syndrome

• Kidney failure

• Skin rash and desquamation may not be present

C sordellii

• Sudden onset after medical abortion; may be within 4–5 days of ingestion of mifepristone

• Abdominal pain

• Absence of fever

• Infection appears to be limited to the uterus, which shows

  • Necrosis

  • Edema

  • Hemorrhage

  • Acute inflammatory changes

Diagnosis

S aureus

• Blood cultures classically are negative because symptoms are due to the effects of the toxin and not to the invasive properties of the organism

C sordellii

• Tachycardia, severe hypotension, capillary leak syndrome with edema

• Profound leukocytosis, hemoconcentration

Treatment

S aureus

• Rapid rehydration

• Antistaphylococcal antibiotics (eg, parenteral nafcillin or oxacillin or, in the penicillin allergic patient, clindamycin)

• Management of kidney or heart failure

• Removal of sources of toxin (eg, removal of tampon, drainage of abscess)

• Intravenous clindamycin, 900 mg every 8 hours, is often added to inhibit toxin production

• Intravenous immune globulin may be considered, although there are limited data compared with streptococcus TSS