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 login to view 1 more bullet Etiology 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 login to view 5 more bullets Staphylococcus aureus Group A Streptococcus (Streptococcus pyogenes) 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 login to view 2 more bullets Studies Labs complete blood count login to view 1 more bullet basic metabolic panel login to view 1 more bullet liver function tests login to view 1 more bullet creatinine kinase login to view 1 more bullet blood cultures and Gram stain arterial blood gas login to view 1 more bullet Differential Other causes of sepsis pneumonia login to view 2 more bullets urinary tract infection login to view 2 more bullets meningitis login to view 2 more bullets Treatment Initial remove the foreign body and control the source of infection Conservative aggressive volume resuscitation login to view 2 more bullets Medical empiric antibiotics login to view 9 more bullets Complications Multiorgan failure (e.g., renal dysfunction and central nervous system involvement