Staphylococcal Toxic Shock Syndrome (TSS)

Epidemiology

  • Distribution of Etiologies
    • Menstrual Cases: account for 55% of all cases
    • Non-Menstrual Cases: account for 45% of all cases

Microbiology

  • Staphylococcus Aureus (see Staphylococcus Aureus)
    • Elaboration of TTST-1 (or Related) Toxin: this toxin is responsible >90% of menstrual cases
      • Illness only occurs in those with lack the antibody against TSST-1
      • Therefore, failure of an initial antibody response may result in recurrences in some cases
    • Elaboration of Enterotoxins B and C1: these toxins are responsible for a high percentage of non-menstrual cases

Exposure

Menstrual/Vaginal/Reproductive Exposure

  • Barrier Contraceptive Use
  • Post-Partum C-Section Wound Infection
  • Post-Partum Vaginal Infection
  • Tampon Use

Skin Site Infection

Foreign-Body Insertion

  • Augmentation Mammoplasty
  • Orthopedic Prosthesis
  • Peritoneal Dialysis (PD) (see Peritoneal Dialysis, [[Peritoneal Dialysis]])
  • Post-Operative Wound Infection: typically occurs on post-operative day #2
  • Sutures

Mucous-Membrane Injury

Deep Tissue Infection

Other

  • Primary Staphylococcal Bacteremia: uncommon etiology of toxic shock syndrome

Diagnosis

  • Blood Culture/Sensitivity: usually negative
  • Vaginal Culture/Sensitivity: may be positive for Staphylococcus Aureus
    • Vaginal colonization (rather than overt infection) is usually present
  • Wound Culture/Sensitivity: may be positive for Staphylococcus Aureus
    • Colonization (rather than overt wound infection) is usually present

Diagnostic Criteria [MEDLINE]

  • Fever (see Fever, [[Fever]]): T >38.9 C
  • Hypotension (see Hypotension, [[Hypotension]]): SBP <90 mm Hg or orthostatic hypotension (drop >15 mm Hg, orthostatic syncpe, orthostatic dizziness)
  • Diffuse Macular Rash (Incuding Palms and Soles) with Desquamation 1-2 Weeks After Onset (see Erythroderma, [[Erythroderma]])
    • Mucosal Membrane Hyperemia
      • Conjunctival Mucosal Membrane Hyperemia
      • Oropharyngeal Mucosal Membrane Hyperemia
      • Vaginal Mucosal Membrane Hyperemia
  • Multisystem Involvement
    • Altered Mental Status/Delirium (see Delirium, [[Delirium]]): in absence of fever or hypotension
    • Azotemia (see Azotemia, [[Azotemia]]): Cr >2x upper limit of normal
    • Diarrhea (see Diarrhea, [[Diarrhea]])
    • Elevated Creatine Kinase (CK) (see Rhabdomyolysis, [[Rhabdomyolysis]]): >2x upper limit of normal
    • Elevated Liver Function Tests (LFT’s) (see xxxx, [[xxxx]]): total bili or transaminases >2x normal
    • Myalgias (see Myalgias, [[Myalgias]])
    • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]]): <100k
    • Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])
  • Negative Serology for Other Diagnoses: including for Measles, Leptospirosis, and Rocky Mountain Spotted Fever
  • Negative Blood and Cerebrospinal Fluid (CSF) Cultures: for organisms other than Staph aureus

Clinical Manifestations

Disease Timing

  • Onset: typically acute
  • Relationship of Onset in Menstrual cases to Menstruation: typically begin 2-3 days after start of menstruation

Dermal Manifestations

  • Scarlatiniform Rash/Erythroderma (“Sunburn-Like” Rash) (see Erythroderma, [[Erythroderma]] and Exanthems, [[Exanthems]])
    • Particularly involves palms and soles (but also involves face, trunk, and extremities)
    • Rash may be subtle and patchy
    • Hyperemia of Mucous Membranes: oropharynx, conjunctiva, and vaginal mucosa (with discharge)
    • Hyperemia of Wound Site: typically without overt wound infection
    • Erythroderma is more common in Staphylococcus-associated toxic shock syndrome cases than in Streptococcus-associated toxic shock syndrome cases
    • Rash typically desquamates over the next 1-2 weeks

Gastrointestinal Manifestations

  • Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
  • Diarrhea (see Diarrhea, [[Diarrhea]]): common
  • Elevated LFT’s (see xxxx, [[xxxx]])
    • Elevated Bilirubin
    • Transaminitis
  • Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])

Hematologic Manifestations

Other Manifestations

  • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]]): may occur early and precede onset of hypotension (which may distinguish toxic shock syndrome from other sepsis syndromes
  • Delirium/Altered Mental Status (see Delirium, [[Delirium]])
    • Lumbar Puncture: normal
  • Fever (see Fever, [[Fever]])
  • Hypoalbuminemia (see Hypoalbuminemia, [[Hypoalbuminemia]])
  • Hypocalcemia (see Hypocalcemia, [[Hypocalcemia]])
  • Hypotension/Orthostasis (see Hypotension, [[Hypotension]]): typically develops within hours of onset of symptoms
  • Myalgias (see Myalgias, [[Myalgias]])
  • Rhabdomyolysis (see Rhabdomyolysis, [[Rhabdomyolysis]])
    • Elevated Creatine Kinase (CK)

Treatment

Antibiotics

  • General Comments: role in treatment is unclear, but likely beneficial to reduce organism carriage and inhibit toxin synthesis
  • Nafcillin or Oxacillin + Clindamycin (see Nafcillin, [[Nafcillin]], Oxacillin, [[Oxacillin]]), and Clindamycin, [[Clindamycin]]): if only methicillin-susceptible Staphylococcus Aureus (MSSA) is suspected
    • Clindamycin is a protein synthesis inhibitor which decreases in vitro toxin synthesis
  • Vancomycin + Clindamycin (see Vancomycin, [[Vancomycin]] and Clindamycin, [[Clindamycin]]): if methicillin-resistant Staphylococcus Aureus (MRSA) is suspected
    • Clindamycin is a protein synthesis inhibitor which decreases in vitro toxin synthesis
  • Linezolid (Zyvox) (see Linezolid, [[Linezolid]]): also decreases in vitro toxin synthesis

Intravenous Immunoglobulin (IVIG) (see Intravenous Immunoglobulin, [[Intravenous Immunoglobulin]])

  • Adjunctive Treatment: blocks the effect of the toxin
    • No randomized trials, but improved mortality in case series

Treat Local Sites of Infection (Source Control)

  • Remove Infected Source: if possible

Supportive Care

  • Management of Sepsis (see Sepsis, [[Sepsis]]): as required
    • Intravenous Fluids
    • Vasopressors
  • Mechanical Ventilation (see General Ventilator Management, [[General Ventilator Management]]): as required

Corticosteroids (see Corticosteroids, [[Corticosteroids]])

  • No Clear Role

Prevention

  • Avoidance of Long-Term Tampon Use

Prognosis

  • Mortality: usually due to ARDS, hypotension, and/or DIC
    • Menstrual-Associated TSS: 5% mortality
    • Non-Menstrual-Associated TSS: 10-15% mortality
    • Streptococcal TSS: 30-70% mortality
  • Recurrence: up to 30% of affected menstruating females may have recurrence (although milder) with future menses
    • Recurrence only occurs in those with lack the anti-TSST-1 antibody

References

  • Case definitions for public health surveillance. MMWR Recomm Rep. 1990 Oct 19;39(RR-13):1-43 [MEDLINE]
  • Toxic shock syndrome: broadening the differential diagnosis. J Am Board Fam Pract. 2001 Mar-Apr;14(2):131-6 [MEDLINE]
  • Staphylococcal toxic shock syndrome. Suspicion and prevention are keys to control. Postgrad Med. 2001 Oct;110(4):55-6, 59-62 [MEDLINE]
  • Intravenous immunoglobulin for treating sepsis and septic shock. Cochrane Database Syst Rev. 2002(1):CD001090 [MEDLINE]