Review Question - QID 102591

This patient with signs of shock, a diffuse, macular, erythematous rash, and a retained tampon on exam likely has toxic shock syndrome. The initial management of toxic shock syndrome is with a broad-spectrum antibiotic regimen to include clindamycin.

Toxic shock syndrome (TSS) occurs due to infection with Staphylococcal or Streptococcal species that produce "super-antigen" toxins, such as TSST-1 produced by S. aureus. These toxins bind directly to the MHC-II receptor on T cells with high affinity causing a massive, sustained cytokine release. The result is a "cytokine storm" causing an intense inflammatory reaction and distributive shock. These infections arise in the setting of a retained tampon or retained nasal packing following nasal surgery; however, this is not always the case. The clinical presentation of TSS is characterized by fever, nausea, vomiting, diarrhea, conjunctivitis, and a diffuse "sunburn-like" rash. Desquamation of the palms and soles typically occurs during recovery, 1-2 weeks after the acute phase of the illness. The initial management of TSS begins with broad spectrum antibiotic therapy. Typical regimens include vancomycin, cefepime, and clindamycin. The initial antibiotic regimen should cover methicillin-resistant S. aureus. Clindamycin is always included due to its ability to suppress bacterial protein production, therefore limiting the production of bacterial toxins. Once a causative organism is identified, antibiotic therapy may be narrowed, though clindamycin is usually administered for the duration of treatment. Extensive supportive care and ICU admission are generally required.

Bryner discusses the wide variety of etiologies of toxic shock syndrome beyond the association with tampons/menstruation, noting that nonmenstrual toxic shock syndrome is often a diagnosis that is initially overlooked. Associated clinical conditions can include barrier contraceptive use, surgical wound infection, burn wounds, cuts or other skin lesions, or arthritis. Approximately 50% of TSS cases are nonmenstrual, with 25% of these occurring in men.

Figure A demonstrates a diffuse, macular, erythematous rash characteristic of Toxic shock syndrome. Note the "sunburn-like" appearance of the rash and the diffuse distribution.

Incorrect Answers:
Answer 1: Intravenous fluid resuscitation and supportive care will likely be required for this patient. However, it is not sufficient alone as this patient also requires broad-spectrum antibiotic therapy.

Answer 2: High dose prednisone may be appropriate for management of Stevens-Johnson syndrome or other similar life threatening rash syndromes. It is not the most appropriate first step in management for this patient with suspected toxic shock syndrome.

Answer 3: Vancomycin alone would not be sufficient. This patient also requires the addition of an agent such as cefepime to cover gram-negative species, as well as clindamycin for the suppression of bacterial toxin production.

Answer 5: Cefazolin and clindamycin may eventually be appropriate if this patient's condition is found to be due to infection with methicillin-sensitive S. aureus. The causative organism has not yet been identified in this case and broad-spectrum antibiotic therapy is warranted.

Bullet Summary:
The initial management of toxic shock syndrome is with a broad-spectrum antibiotic regimen to include clindamycin.