Toxic shock syndrome overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2], Syed Hassan A. Kazmi BSc, MD [3]
Overview
Toxic shock syndrome (TSS) is a rare, but potentially fatal disease caused by bacterial toxins. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative agents are the Gram-positive bacteria Staphylococcus aureus and Streptococcus pyogenes. Streptococcal TSS is sometimes referred to as toxic shock-like-syndrome (TSLS) . Some cases maybe caused by Clostridium sordellii, influenza virus and varicella zoster virus. The syndrome consists of sudden onset of fever, chills, vomiting, diarrhea, muscle aches, hypotension and a scarlantiform rash. Diagnosis of toxic Shock Syndrome (TSS) is mainly based on the clinical presentation. The initial management of toxic shock syndrome involves the removal of any foreign materials such as tampons, vaginal sponges, or nasal packing. Antimicrobial therapy is indicated in toxic shock syndrome. Supportive therapy for toxic shock syndrome includes intravenous fluids, control of blood pressure, and dialysis in cases of renal failure. Patients with multiple organ failure are admitted to the intensive care unit.
Historical Perspective
The term toxic shock syndrome was first used in 1978 by a Denver pediatrician, Dr. J.K. Todd, to describe the staphylococcal illness in three boys and four girls aged 8-17 years.[1] Even though S. aureus was isolated from mucosal sites from the patients, bacteria could not be isolated from the blood, cerebrospinal fluid, or urine, raising suspicion that a toxin was involved. The authors of the study noted that reports of similar staphylococcal illnesses had appeared occasionally as far back as 1927. Most notably, the authors at the time failed to consider the possibility of a connection between toxic shock syndrome and tampon use, as three of the girls who were menstruating when the illness developed were using tampons.[2]
Classification
Toxic shock syndrome may be classified based on the microbiological organisms involved in causing the disease. Commonly involved organisms are Staphylococcus aureus and Streptococcus pyogenes (GAS). Less commonly involved organisms leading to the development of toxic shock syndrome are Clostridium sordelli, Influenza and Varicella Zoster virus (the etiological agent of chickenpox).
Pathophysiology
The pathophysiology of toxic shock syndrome can be explained based on the etiological agent causing the disease. The general mechanism for all the etiological agents is the same, which involves non-specific activation of T lymphocytes by toxins acting as superantigens leading to release of cytokines. There are small differences in the mechanism of cytokine production which can be explained individually for the organisms involved.
Causes
Toxic shock syndrome is caused by a toxin produced by certain types of Staphylococcus bacteria. A similar syndrome, called toxic shock-like syndrome (TSLS), can be caused by streptococcal bacteria. Some cases of toxic shock syndrome have been known to be caused by Clostridium sordellii, influenza virus and varicella zoster virus.
Differentiating Toxic Shock Syndrome from other Diseases
Toxic shock syndrome (TSS) may have a similar presentation to some diseases which present as a rash, fever and hypotension. Some features are unique to toxic shock syndrome and can be used to differentiate it from other diseases.
Epidemiology and Demographics
Toxic shock syndrome (TSS) became a nationally notifiable disease in 1980. After the initial epidemic, the number of reported cases decreased significantly. Close observation during 1986 which was conducted in different parts of the United States, confirms the decreasing trend. Currently, the total incidence is 0.5 per 100,000 population. Incidence rates declined from 6 to 12 per 100,000 among women 12-49 years of age in 1980 to 1 per 100,000 among women 15-44 years of age in 1986.[1] Apart from menstruation associated TSS, non-menstruating cases having a skin or soft tissue infection have also been identified.[2]
Risk Factors
Menstruating women, women using barrier contraceptive devices, persons who have undergone nasal surgery, and persons with postoperative staphylococcal wound infections are the most important risk factors for toxic shock syndrome.
Natural History, Complication and Prognosis
If left untreated toxic shock syndrome after initial presentation, may rapidly lead to multi-organ system failure with serious morbidity and mortality. Appropriate treatment leads to full recovery of the patient.
Diagnosis
Diagnostic Criteria
Diagnosis of Toxic Shock Syndrome (TSS) is mainly based on the clinical presentation.
History and Symptoms
The most common symptoms of TSS include fever, erythroderma, and general viral infection symptoms like myalgia. Less common symptom of TSS include desquamation (which occur after 1-3 weeks of disease onset).
Physical Examination
Patients with toxic shock syndrome (TSS) usually present with shock. Physical examination of patients with TSS is usually remarkable for hypotension, fever, and diffuse erythroderma. The presence of desquamation on physical examination is highly suggestive of TSS.
Laboratory Findings
Laboratory findings consistent with the diagnosis of toxic shock syndrome (TSS) include leukocytosis, anemia and thrombocytopenia. A positive blood culture is diagnostic for Streptococcal TSS, although in other causes of TSS blood culture doesn't have a high value.
X-Rays
On chest x-ray, toxic shock syndrome (TSS) is characterized by diffuse bilateral interstitial and alveolar infiltrates due to ARDS.
CT Scan
On brain CT-scan, toxic shock syndrome (TSS) is characterized by a midline shift, or effacement of the basilar cisterns due to cerebral edema.
MRI
There are no MRI findings associated with toxic shock syndrome (TSS).
Other Imaging Studies
There are no other specific imaging findings for toxic shock syndrome (TSS).
Other Diagnostic Studies
Although the best diagnostic tool for toxic shock syndrome (TSS) diagnosis is with clinical findings and laboratory exams, there are still some specific diagnostic ways to confirm TSS diagnosis. These techniques include frozen section biopsy and staphylococcus aureus antibody testing.
Treatment
Medical Therapy
Women wearing a tampon at the onset of symptoms should remove it immediately. The severity of this disease results in hospitalization for treatment. Antibiotic treatment consists of penicillin and clindamycin.
Surgery
One of the symptoms of streptococcal toxic shock syndrome is extreme infection of the skin and deeper parts is called necrotizing fasciitis. This often requires prompt surgical treatment.
Primary Prevention
Menstrual toxic shock syndrome can be prevented by avoiding the use of highly absorbent tampons. Risk can be reduced by changing tampons more frequently and using tampons only once in a while during menstruation.
Secondary Prevention
Secondary prevention strategies following toxic shock syndrome (TSS) include chemoprophylaxis for invasive group A streptococcus or staphylococcuscarriers. Although it is still not certain to be helpful.