Updated: 12/19/2019

Toxic Shock Syndrome

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Snapshot
  • A 19-year-old woman presents to the emergency department for worsening myalgias, chills, nausea, and generalized weakness. Her symptoms began approximately 5 days ago. She denies any recent travel history or sick contacts and states she is currently menstruating and using tampons. Her temperature is 102.0°F (38.9°C), blood pressure is 88/55 mmHg, and pulse is 115/min. Physical examination is remarkable for confusion and widespread macular blanching erythroderma that appears like a sunburn. Laboratory studies are significant for a leukocyte count of 17,000/mm3 with a neutrophilic predominance. Blood and urine cultures are obtained. She is admitted to the medical intensive care unit and is receiving aggressive fluid resuscitation and intravenous vancomycin and clindamycin. (Toxic shock syndrome caused by Staphylococcus aureus)
Introduction
  • Definition
    • a toxin-mediated and life-threatening illness that results in hypotension and multiorgan failure
  • Epidemiology
    • incidence
      • staphylococcal toxic shock syndrome is more common in women due to tampon use 
        • typically occurs within 5 days of onset of menses in women using tampons
  • Etiology
    • Staphylococcus aureus
    • group A Streptococcus (Streptococcus pyogenes)
  • Pathophysiology
    • TSST-1 (in Staphylococcus aureus) or erythrogenic exotoxin A (in Streptococcus pyogenes) cross-links the β region of the T-cell receptor to MHC class II on the antigen presenting cell outside the antigen binding site
      • this cross-linking creates a superantigen, which leads to an overwhelming release of
        • IL-1
        • IL-2
        • IFN-γ
        • TNF-β
Presentation
  • Symptoms
    • confusion
    • chills
    • myalgias
    • nausea
    • vomiting
  • Physical exam
    • fever 102.0°F (38.9°C) 
    • hypotension (systolic blood pressure ≤ 90 mmHg)
    • localized swelling and erythema
    • rash
      • diffuse macular erythroderma (in staphylococcal cases)
      • necrotizing soft tissue infection (in group A strep cases)
Studies
  • Labs
    • complete blood count
      • a leukocytosis with left shift can be seen
    • basic metabolic panel
      • useful looking at creatinine to see if there is renal involvement
    • liver function tests
      • may see elevated transaminases and coagulopathy
    • creatinine kinase
      • may be elevated in myositis or necrotizing fasciitis
    • blood cultures and Gram stain
    • arterial blood gas 
      • metabolic acidosis (anaerobic metabolism) with respiratory compensation (low pCO2)
Differential
  • Other causes of sepsis
    • pneumonia
      • differentiating factors
        • patients will have a productive cough with supportive chest imaging findings (e.g., lobar involvement)
    • urinary tract infection
      • differentiating factor
        • patients will likely have dysuria and urinalysis demonstrating pyuria and urine culture growing an organism
    • meningitis
      • differentiating factor
        • patients may have a headache with neck stiffness
Treatment
  • Conservative
    • aggressive volume resuscitation 
      • indication
        • to improve hypotension
  • Medical
    • empiric antibiotics
      • indication
        • to address the underlying organism
      • regimen
        • penicillin G and clindamycin (in Streptococcus pyogenes)
        • vancomycin (or linezolid) and clindamycin (in Staphylococcus aureus)
      • comments
        • it is important to narrow your antibiotics once sensitivity testing returns
          • if Staphylococcus aureus is susceptible to nafcillin, then discontinue vancomycin and treat with nafcillin
Complications
  • Multiorgan failure (e.g., renal dysfunction and central nervous system involvement
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.ID.15.4678) A 22-year-old female is hospitalized with fever and hypotension refractory to fluid resuscitation. Her vital signs are as follows: T 39.0 C, P 110, BP 86/52, RR 12, SpO2 98%. Physical exam reveals diffuse macular erythroderma (Figure A) and the following findings of the conjunctiva (Figure B) and oral cavity (Figure C). She complains of muscle aches as well as diarrhea for the past 3 days. She denies any recent travel or new sexual partners. She had her last menses 4 days ago and always uses a tampon. What is the most likely organism to cause this patient’s presentation? Review Topic | Tested Concept

QID: 107258
FIGURES:
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A single-stranded, negative-sense, enveloped RNA virus

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An aerobic, gram-negative coccobacilli

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An aerobic, gram-positive cocci in chains

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A facultative anaerobic, gram-positive cocci in clusters

72%

(13/18)

5

A coiled, obligate aerobic, spirochete

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L 2 C

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