TOXIC SHOCK SYNDROME
Toxic shock syndrome (TSS) is an uncommon, potentially life-threatening condition caused by toxins produced by an infection with Staphylococcus aureus. Toxic shock syndrome is rare, being seen in only 1 to 2/100,000 women 15 to 44 years old (last active surveillance done in 1987).
Toxic shock syndrome requires infection by S. aureus and is associated with the use of super-absorbency tampons, or prolonged use of regular tampons, or barrier contraceptive devices. Although most commonly associated with prolonged tampon use, about 10% of TSS cases are associated with other conditions, including postoperative staphylococcal wound infections and nonsurgical focal infections. Postpartum cases (including transmission to the neonate) have been reported. Even the use of laminaria to dilate the cervix has been reported to be associated with rare cases. Overall, the prevalence of toxic shock syndrome appears to have declined with newer menstrual hygiene products and awareness of more appropriate use patterns.
Patients with toxic shock syndrome experience rapid onset of fever higher than 38.9°C (102°F), hypotension, and a diffuse rash that is commonly absent in places where clothing presses tightly against the skin. The hypotension seen may progress to severe and intractable hypotension and ventilatory and multisystem dysfunction or failure. Patients may also exhibit agitation, arthralgias, confusion, and diarrhea. Nonspeciﬁc symptoms also include headache, myalgias, nausea, and vomiting. Desquamation, particularly on the palms and soles, can occur 1 to 2 weeks after onset of the illness. Many of these symptoms can mimic other exanthems or gastrointestinal illnesses, making a high degree of suspicion a prerequisite to establishing the correct diagnosis. The characteristics that deﬁne toxic shock syndrome are shown below.
The pathophysiology of TSS involves exotoxins produced by S. aureus; toxic shock syndrome toxin-1; and enterotoxins A, B, and C. For toxic shock to develop, three conditions must be met: there must be colonization by the bacteria, it must produce toxin, and there must be a portal of entry for the toxin. The presence of foreign bodies, such as a tampon, is thought to reduce local magnesium levels, which promotes the formation of toxin by the bacteria.
The management of patients with TSS consists of rapid evaluation and supportive intervention. Aggressive support and treatment of the attendant shock are paramount. (Frank shock is common by the time the patient is ﬁrst seen for care.) The site of infection must be identiﬁed and drained, most commonly by removing the contaminated tampon. Antibiotic therapy with a-lactamase–resistant antistaphylococcal agent should be started early, but it does not alter the initial course of the illness. Other support (e.g., mechanical ventilation or pressor agents) may be needed. Adult respiratory distress syndrome is a common sequela of TSS and patients must be monitored for the development of this complication. Acute renal failure, alopecia, and nail loss may also occur in these patients.
CHARACTERISTICS THAT DEFINE TOXIC SHOCK SYNDROME
• Fever >38.9°C (102°F)
• Diffuse, macular, erythematous rash
• Desquamation of palms and soles 1 to 2 weeks after onset
• Hypotension (90 torr systolic or orthostatic change)
• Negative blood, pharyngeal, and cerebrospinal ﬂuid cultures
• Negative serologic tests for measles, leptospirosis, Rocky Mountain spotted fever
• Three or more of the following organ systems:
° Cardiopulmonary (respiratory distress, pulmonary edema, heart block, myocarditis
° Central nervous (disorientation or altered sensorium)
° Gastrointestinal (vomiting, diarrhea)
• Hematologic (thrombocytopenia of 100,000/mm3)
• Hepatic (>2-fold elevation of total bilirubin or liver enzymes, serum albumin >2 g/dL)
• Mucous membrane inﬂammation (vaginal, oropharyngeal, conjunctival)
• Musculoskeletal (myalgia, >2-fold elevation of creatine phosphokinase)
• Renal (pyuria, >2-fold elevation of blood urea nitrogen or creatinine)