TOXIC SHOCK SYNDROME
Toxic shock syndrome (TSS)
is an uncommon, potentially life-threatening condition caused by toxins
produced by an infection with Staphylococcus aureus. Toxic shock
syndrome is rare, being seen in only 1 to 2/100,000 women 15 to 44 years old
(last active surveillance done in 1987).
Toxic shock syndrome requires infection by S. aureus and is associated with the use of super-absorbency tampons, or prolonged use of regular tampons, or barrier contraceptive devices. Although most commonly associated with prolonged tampon use, about 10% of TSS cases are associated with other conditions, including postoperative staphylococcal wound infections and nonsurgical focal infections. Postpartum cases (including transmission to the neonate) have been reported. Even the use of laminaria to dilate the cervix has been reported to be associated with rare cases. Overall, the prevalence of toxic shock syndrome appears to have declined with newer menstrual hygiene products and awareness of more appropriate use patterns.
Patients with toxic shock syndrome experience rapid onset of fever higher
than 38.9°C (102°F), hypotension, and a diffuse rash that is commonly absent in
places where clothing presses tightly against the skin. The hypotension seen
may progress to severe and intractable hypotension and ventilatory and
multisystem dysfunction or failure. Patients may also exhibit agitation,
arthralgias, confusion, and diarrhea. Nonspecific symptoms also include
headache, myalgias, nausea, and vomiting. Desquamation, particularly on the palms
and soles, can occur 1 to 2 weeks after onset of the illness. Many of these
symptoms can mimic other exanthems or gastrointestinal illnesses, making a high
degree of suspicion a prerequisite to establishing the correct diagnosis. The
characteristics that define toxic shock syndrome are shown below.
The pathophysiology of TSS involves exotoxins produced by S. aureus;
toxic shock syndrome toxin-1; and enterotoxins A, B, and C. For toxic shock to
develop, three conditions must be met: there must be colonization by the
bacteria, it must produce toxin, and there must be a portal of entry for the
toxin. The presence of foreign bodies, such as a tampon, is thought to reduce
local magnesium levels, which promotes the formation of toxin by the bacteria.
The management of patients with TSS consists of rapid evaluation and
supportive intervention. Aggressive support and treatment of the attendant
shock are paramount. (Frank shock is common by the time the patient is first
seen for care.) The site of infection must be identified and drained, most
commonly by removing the contaminated tampon. Antibiotic therapy with
a-lactamase–resistant antistaphylococcal agent should be started early, but it
does not alter the initial course of the illness. Other support (e.g., mechanical
ventilation or pressor agents) may be needed. Adult respiratory distress
syndrome is a common sequela of TSS and patients must be monitored for the
development of this complication. Acute renal failure, alopecia, and nail loss may also occur in these patients.
CHARACTERISTICS
THAT DEFINE TOXIC SHOCK
SYNDROME
•
Fever >38.9°C (102°F)
•
Diffuse, macular, erythematous rash
•
Desquamation of palms and soles 1 to 2 weeks
after onset
•
Hypotension (90 torr systolic or orthostatic
change)
•
Negative blood, pharyngeal, and cerebrospinal
fluid cultures
•
Negative serologic tests for measles,
leptospirosis, Rocky Mountain spotted fever
•
Three or more of the following organ systems:
°
Cardiopulmonary (respiratory distress,
pulmonary edema, heart block, myocarditis
°
Central nervous (disorientation or altered
sensorium)
°
Gastrointestinal (vomiting, diarrhea)
•
Hematologic (thrombocytopenia of 100,000/mm3)
•
Hepatic (>2-fold elevation of total bilirubin or liver enzymes, serum albumin >2 g/dL)
•
Mucous membrane inflammation (vaginal,
oropharyngeal, conjunctival)
•
Musculoskeletal (myalgia, >2-fold elevation of creatine phosphokinase)
•
Renal (pyuria, >2-fold elevation of blood urea nitrogen or
creatinine)
