Updated: 7/5/2021

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
  • Initial
    • remove the foreign body and control the source of infection 
  • Conservative
    • aggressive volume resuscitation 
      • indication
        • to improve hypotension
  • Medical
    • empiric antibiotics
      • indication
        • to address the underlying organism
      • regimen
        • clindamycin - preferred first for toxin suppression 
        • 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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(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?

QID: 107258
FIGURES:
1

A single-stranded, negative-sense, enveloped RNA virus

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(0/22)

2

An aerobic, gram-negative coccobacilli

9%

(2/22)

3

An aerobic, gram-positive cocci in chains

23%

(5/22)

4

A facultative anaerobic, gram-positive cocci in clusters

64%

(14/22)

5

A coiled, obligate aerobic, spirochete

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(0/22)

M 6 C

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