Toxic shock syndrome differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Differentiating Toxic Shock Syndrome from other Diseases
Toxic shock syndrome requires all 3 manifestations of fever, hypotension and diffuse scarlatiniform rash (innumerable small red papules that are diffusely distributed plus erythema, which blanches and desquamates one or two weeks after onset of illness). It presents with various signs of infection, hemodynamic dysfunction and organ failure.
Clinical presentation of sepsis and rash needs to be differentiated from other diseases like:
- Staphylococcal scalded skin syndrome
- Exfoliative erythroderma syndrome
- Erythema multiforme major
- Drug eruption
| Disease | Epidemiology | Predisposing factors | Clinical features | Lab abnormalities | |
|---|---|---|---|---|---|
| Signs | Symptoms | ||||
| Toxic shock syndrome | Occurs in both adults and children (9:1 female predominance) | Occurs in association with vaginitis during menstruation following tampon use (S. aureus); as a complication of soft tissue infections (S. pyogenes or GAS) or in females undergoing medical abortion (C. sordelii). | Hypotension, tachycardia, mucous membrane hyperemia (vaginal, oral, conjunctival) | Fever, diarrhea, vomiting, diffuse scarlantiform rash | Hyponatremia and uremia. Hepatic dysfunction (total bilirubin, serum asparate aminotransferase or serum alanine aminotransferase levels >2 times upper normal limit), leukocytosis with a polymorphonuclear shift to the left. Platelets < 100,000 per mm3 (thrombocytopenia) |
| Kawasaki | Occurs in children, usually age 1-4 years | Interaction of genetic and environmental factors, possibly including an infection in combination with genetic predisposition to an autoimmune mechanism (autoimmune vasculitis) | Non-suppurative, painless bilateral conjunctival inflammation (conjunctivitis), strawberry tongue (marked redness with prominent gustative papillae), deep transverse grooves across the nails may develop (Beau’s lines), lymphadenopathy present(acute, non-purulent, cervical), may lead to coronary artery anerysms, | High and persistent fever that is not very responsive to normal treatment with acetaminophen or NSAIDs, diffuse macular-papular erythematous rash | Liver function tests may show evidence of hepatic inflammation and low serum albumin levels, low hemoglobulin and age-adjusted hemoglobulin concentrations, thrombocytosis, anemia. Echocardiographic abnormalities, such as valvulitis (mitral or tricuspid regurgitation) and coronary artery lesions, are significantly more common in the Kawasaki disease. [1] |
| Scarlet fever | Distributed equally among both genders. Most commonly affects children between five and fifteen years of age. | Occurs after streptococcal pharyngitis/tonsillitis | Pastia's sign (puncta and skin crease accentuation of the erythema), strawberry tongue, cervical lymphadenopathy may be present. Scarlet fever appears similar to Kawasaki's disease in some aspects, but lacks the eye signs or the swollen, red fingers and toes | Characteristic sandpaper-like rash which appears days after the illness begins (although the rash can appear before illness or up to 7 days later), rash may first appear on the neck, underarm, and groin | Leukocytosis with left shift and possibly eosinophilia a few weeks after convalescence. Anti-deoxyribonuclease B, antistreptolysin-O titers (antibodies to streptococcal extracellular products), antihyaluronidase, and antifibrinolysin may be positive. |
| Features | Toxic shock syndrome | Kawasaki disease | Scarlet fever |
|---|---|---|---|
| Epidemiology | Occurs in both adults and children (9:1 female predominance) | Occurs in children, usually age 1-4 years | Distributed equally among both genders. Most commonly affects children between five and fifteen years of age. |
| Predisposing factors | Occurs in association with vaginitis during menstruation following tampon use (S. aureus); as a complication of soft tissue infections (S. pyogenes or GAS) or in females undergoing medical abortion (C. sordelii). | Interaction of genetic and environmental factors, possibly including an infection in combination with genetic predisposition to an autoimmune mechanism (autoimmune vasculitis) | Occurs after streptococcal pharyngitis/tonsillitis |
| Hypotension | Commonly present | Not present | Uncommon |
| Diarrhea | Present | May be present | Not present |
| Pastia's sign (puncta and skin crease accentuation of the erythema) | Not present | Not present | Present |
| Renal faliure | Present | Not present | Uncommon |
| Pyuria | Renal origin | Uretheral origin | |
| Lymphadenopathy and conjunctvitis | Not present | Present(acute, non-purulent, cervical) | Cervical lymphadenopathy may be present. Scarlet fever appears similar to Kawasaki's disease in some aspects, but lacks the eye signs or the swollen, red fingers and toes |
| Metabolic and electrolyte imbalances | Present (hyponatremia and uremia). Hepatic (total bilirubin, serum asparate aminotransferase or serum alanine aminotransferase levels >2 times upper normal limit) | Liver function tests may show evidence of hepatic inflammation and low serum albumin levels | Not present |
| Hematologic and cardiovascular testing | Leukocytosis with a polymorphonuclear shift to the left. Platelets < 100,000 per mm3 | Low hemoglobulin and age-adjusted hemoglobulin concentrations, thrombocytosis, anemia. Echocardiographic abnormalities, such as valvulitis (mitral or tricuspid regurgitation) and coronary artery lesions, are significantly more common in the Kawasaki disease. [1] | Leukocytosis with left shift and possibly eosinophilia a few weeks after convalescence. Anti-deoxyribonuclease B, antistreptolysin-O titers (antibodies to streptococcal extracellular products), antihyaluronidase, and antifibrinolysin may be positive. |