Toxic shock syndrome diagnostic criteria: Difference between revisions

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== Overview ==
== Overview ==
The diagnostic criteria varies depend on the [[organism]] responsible for the [[Toxic shock syndrome|Toxic Shock Syndrome]] (TSS), but mainly the diagnosis of TSS is based on the clinical presentation.  
Diagnosis of [[Toxic shock syndrome|Toxic Shock Syndrome]] (TSS) is mainly based on the clinical presentation including [[fever]] >38.9°C, [[hypotension]], diffuse [[erythroderma]], [[desquamation]].  
 
==Diagnostic Criteria==
==Diagnostic Criteria==
=== Toxic Shock Syndrome (Other Than Streptococcal) (TSS) ===
=== Toxic Shock Syndrome (Other Than Streptococcal) (TSS) ===


==== Clinical Criteria ====
==== Clinical Criteria ====
The diagnosis of [[Staphylococcus|Staphylococcal]] [[toxic shock syndrome]] (TSS) is based upon clinical presentation as no confirmatory diagnostic criteria is developed yet. A criteria list have been established by United States Centers for Disease Control and Prevention ([[Centers for Disease Control and Prevention|CDC]]) for [[Epidemiology|epidemiologic]] studies on [[Staphylococcus|Staphylococcal]] TSS, mean that a patient can not be excluded from disease based on the absence of one of these criterias when it come to [[diagnosis]] terms. This [[criteria]] list means that a confirmed case is someone who has [[fever]] >38.9°C, [[hypotension]], diffuse [[erythroderma]], [[desquamation]] (unless the patient dies before [[desquamation]] can occur), and involvement of at least three organ systems. If a patient misses one of these criterias, the case may be considered as a probable/susceptible case.<ref name="pmid7289007">{{cite journal |vauthors=Tofte RW, Williams DN |title=Toxic shock syndrome. Evidence of a broad clinical spectrum |journal=JAMA |volume=246 |issue=19 |pages=2163–7 |year=1981 |pmid=7289007 |doi= |url=}}</ref>
The diagnosis of [[Staphylococcus|Staphylococcal]] [[toxic shock syndrome]] (TSS) is based upon clinical presentation. An epidemiological clinical criteria list has been established by United States Centers for Disease Control and Prevention ([[Centers for Disease Control and Prevention|CDC]]) for [[Epidemiology|epidemiologic]] studies on [[Staphylococcus|Staphylococcal]] TSS. This criteria list is epidemiologicaly usable only, meaning that a patient can not be excluded from disease based on the absence of one of these criteria. This [[criteria]] list points that a confirmed case is someone who has [[fever]] >38.9°C, [[hypotension]], diffuse [[erythroderma]], [[desquamation]] (unless the patient dies before [[desquamation]] can occur), and involvement of at least three organ systems. If a patient misses one of these criteria, the case may be considered as a probable/susceptible case.<ref name="pmid7289007">{{cite journal |vauthors=Tofte RW, Williams DN |title=Toxic shock syndrome. Evidence of a broad clinical spectrum |journal=JAMA |volume=246 |issue=19 |pages=2163–7 |year=1981 |pmid=7289007 |doi= |url=}}</ref>


An [[illness]] with the following clinical manifestations:
[[Toxic shock syndrome|TSS]] diagnosis can be made with the following clinical manifestations:
* [[Fever]]: [[Temperature]] greater than or equal to 102.0°F (greater than or equal to 38.9°C)
* [[Fever]]: [[Temperature]] greater than or equal to 102.0°F (greater than or equal to 38.9°C)
* [[Rash]]: Diffuse [[macular]] [[erythroderma]]
* [[Rash]]: Diffuse [[macular]] [[erythroderma]]
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* [[Hypotension]]: [[Systolic blood pressure]] less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years
* [[Hypotension]]: [[Systolic blood pressure]] less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years
* [[Multiorgan failure|Multiorgan involvement]] (three or more of the following organ systems):
* [[Multiorgan failure|Multiorgan involvement]] (three or more of the following organ systems):
** [[Gastrointestinal]]: [[Vomiting]] or [[diarrhea]] at onset of [[illness]]
** [[Gastrointestinal]]:
** [[Muscular]]: Severe myalgia or creatine phosphokinase level at least twice the upper limit of normal
*** [[Vomiting]]
** [[Mucous membrane]]: [[Vaginal]], [[oropharyngeal]], or [[Conjunctival disease|conjunctival hyperemia]]
*** [[Diarrhea]] at onset of [[illness]] (especially watery)
** [[Kidney|Renal]]: [[Blood urea nitrogen]] or [[creatinine]] at least twice the upper limit of normal for laboratory or urinary sediment with [[pyuria]] (greater than or equal to 5 [[leukocytes]] per high-power field) in the absence of [[urinary tract infection]]
** [[Muscular]]:
** [[Hepatic]]: [[Bilirubin|Total bilirubin]], [[Alanine aminotransferase|alanine]] [[aminotransferase]] enzyme, or [[Aspartate|aspartate aminotransferase]] enzyme levels at least twice the upper limit of normal for laboratory
*** Severe [[myalgia]]
** [[Hematologic]]: [[Platelets]] less than 100,000/mm3
*** Increased [[creatine phosphokinase]] ([[CPK]]) level at least twice the upper limit of normal
** [[Central nervous system]]: [[Disorientation]] or alterations in [[consciousness]] without [[focal neurologic signs]] when [[fever]] and [[hypotension]] are absent.<ref name="pmid2294395"><nowiki>cite journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}</nowiki></ref><ref name="pmid9148133">{{cite journal |vauthors= |title=Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention |journal=MMWR Recomm Rep |volume=46 |issue=RR-10 |pages=1–55 |year=1997 |pmid=9148133 |doi= |url=}}</ref>
** [[Mucous membrane]] [[Conjunctival disease|inflammation]]:  
***[[Vaginal]]
***[[Oropharyngeal]]  
***[[Conjunctival disease|Conjunctival]]  
** [[Kidney|Renal]]:
*** [[Blood urea nitrogen]] or [[creatinine]] at least twice the upper limit of normal.
*** Urinary sediment with [[pyuria]] (greater than or equal to 5 [[leukocytes]] per high-power field) in the absence of [[urinary tract infection]]
** [[Hepatic]]: Increase of the hepatic enzymes twice the upper limit of normal.
*** [[Bilirubin|Total bilirubin]]
*** [[Alanine aminotransferase|Alanine]] [[aminotransferase]]
*** [[Aspartate|Aspartate aminotransferase]]
** [[Hematologic]]:  
*** [[Platelets]] less than 100,000/mm3
** [[Central nervous system]]:  
*** [[Disorientation]] or alterations in [[consciousness]] without [[focal neurologic signs]].<ref name="pmid2294395"><nowiki>cite journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}</nowiki></ref><ref name="pmid9148133">{{cite journal |vauthors= |title=Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention |journal=MMWR Recomm Rep |volume=46 |issue=RR-10 |pages=1–55 |year=1997 |pmid=9148133 |doi= |url=}}</ref>


==== Laboratory Criteria for Diagnosis ====
==== Laboratory Criteria for Diagnosis ====
Negative results on the following tests, if obtained:
If the result of the following tests become negative, it can be considered a positive criteria for TSS:
* [[Blood]] or [[cerebrospinal fluid]] cultures. Blood culture may be positive for [[Staphylococcus aureus]].
* [[Blood]] culture: Blood culture may be positive for [[Staphylococcus aureus]].
* Negative [[Serology|serologies]] for [[Rocky Mountain spotted fever]], [[leptospirosis]], or [[measles]].<ref name="urlToxic Shock Syndrome (Other Than Streptococcal) | 2011 Case Definition">{{cite web |url=https://wwwn.cdc.gov/nndss/conditions/toxic-shock-syndrome-other-than-streptococcal/case-definition/2011/ |title=Toxic Shock Syndrome (Other Than Streptococcal) &#124; 2011 Case Definition |format= |work= |accessdate=}}</ref>
* C[[cerebrospinal fluid|erebrospinal fluid]] cultures
* Negative [[Serology|serologies]] for:
** [[Rocky Mountain spotted fever|Rocky Mountain Spotted Fever]]
** [[Leptospirosis]]
** [[Measles]]<ref name="urlToxic Shock Syndrome (Other Than Streptococcal) | 2011 Case Definition">{{cite web |url=https://wwwn.cdc.gov/nndss/conditions/toxic-shock-syndrome-other-than-streptococcal/case-definition/2011/ |title=Toxic Shock Syndrome (Other Than Streptococcal) &#124; 2011 Case Definition |format= |work= |accessdate=}}</ref>


=== Streptococcal TSS ===
=== Streptococcal TSS ===
There is a subtle difference between [[Streptococcus|Streptococcal]] TSS and other types. [[Streptococcus|Group A Streptococcus(GAS]]) can be isolated in GAS-related TSS patients.
There is a subtle difference between [[Streptococcus|Streptococcal]] TSS and other types. [[Streptococcus|Group A Streptococcus(GAS]]) can be isolated in GAS-related TSS patients.
* Clinical and biochemical criteria of [[Streptococcus|streptococcal]] TSS and [[necrotizing fasciitis]] (NF).<ref name="urlwwwnc.cdc.gov">{{cite web |url=https://wwwnc.cdc.gov/eid/article/1/3/pdfs/95-0301.pdf |title=wwwnc.cdc.gov |format= |work= |accessdate=}}</ref>
====Clinical and biochemical criteria of [[Streptococcus|streptococcal]] TSS and [[necrotizing fasciitis]] (NF).<ref name="urlwwwnc.cdc.gov">{{cite web |url=https://wwwnc.cdc.gov/eid/article/1/3/pdfs/95-0301.pdf |title=wwwnc.cdc.gov |format= |work= |accessdate=}}</ref>====
{| class="wikitable"
{| class="wikitable"
!Disease presentation
! align="center" style="background:#4479BA; color: #FFFFFF;" |Disease Presentation
! colspan="2" |criteria
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Criteria
!Definite case
! align="center" style="background:#4479BA; color: #FFFFFF;" |Definite case
!Suspected case
! align="center" style="background:#4479BA; color: #FFFFFF;" |Suspected case
|-
|-
! rowspan="2" |Streptococal TSS
! rowspan="2" align="center" style="background:#DCDCDC;"|Streptococal TSS
|A. Isolation of group A [[Streptococcus]]
|A. Isolation of group A [[Streptococcus]]
|1. From a [[sterile]] site  
|1. From a [[sterile]] site  


2. From a nonsterile body site
2. From a nonsterile body site
| rowspan="2" |A1+B
| rowspan="2" |A1 '''+''' B(complete)
| rowspan="2" |A2+B
 
| rowspan="2" |A2 '''+''' B(complete)
 
|-
|-
|B. Clinical signs of severity
|B. Clinical signs of severity
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* [[Hypotension]]
* [[Hypotension]]
* Clinical and laboratory abnormalities (requires two or more of the following):  
* Clinical and laboratory abnormalities (requires two or more of the following):  
** [[Renal Failure]]
** [[Renal Failure]]
** [[Coagulopathy]]
** [[Coagulopathy]]
** [[Hepatic failure]]
** [[Hepatic failure]]
** [[Acute respiratory distress syndrome]](ARDS)
** [[Acute respiratory distress syndrome]] (ARDS)
** Extensive tissue [[necrosis]], i.e. necrotizing fasciitis
** Extensive tissue [[necrosis]] i.e. necrotizing fasciitis
** [[Erythematous]] [[rash]]
** [[Erythematous]] [[rash]]
|-
|-
! rowspan="2" |Necrotizing fasciitis
! rowspan="2" align="center" style="background:#DCDCDC;"|Necrotizing fasciitis
|A. Clinical Criteria
|A. Clinical Criteria
|
|
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*** [[Hepatic failure|Liver failure]]
*** [[Hepatic failure|Liver failure]]
*** [[Renal failure]]
*** [[Renal failure]]
| rowspan="2" |A+B1
| rowspan="2" |A (complete) '''+''' B1
| rowspan="2" |A+B2
 
A+B3
| rowspan="2" |A (complete) '''+''' B2
A(complete) '''+''' B3
 
|-
|-
|B. Isolation of group A [[Streptococcus]]
|B. Isolation of group A [[Streptococcus]]
|
|
# Isolation of group A [[Streptococcus]] from a normally [[sterile]] body site
# Isolation of group A [[Streptococcus]] from a normally [[sterile]] body sites
# [[Serological testing|Serologic]] confirmation of group A [[Streptococcus|streptococcal]] infection by a 4-fold rise against: a) streptolysin O b) DNase B
# [[Serological testing|Serologic]] confirmation of group A [[Streptococcus|streptococcal]] infection by a 4-fold rise against:
# [[Histologic]] confirmation: [[Gram-positive cocci]] in a [[Necrotic tissue|necrotic soft tissue infection]]
::a) streptolysin O b) [[DNase|DNase B]]
:3. [[Histologic]] confirmation: [[Gram-positive cocci]] in a [[Necrotic tissue|necrotic soft tissue infection]]
|}
|}


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Latest revision as of 00:26, 30 July 2020

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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]

Overview

Diagnosis of Toxic Shock Syndrome (TSS) is mainly based on the clinical presentation including fever >38.9°C, hypotension, diffuse erythroderma, desquamation.

Diagnostic Criteria

Toxic Shock Syndrome (Other Than Streptococcal) (TSS)

Clinical Criteria

The diagnosis of Staphylococcal toxic shock syndrome (TSS) is based upon clinical presentation. An epidemiological clinical criteria list has been established by United States Centers for Disease Control and Prevention (CDC) for epidemiologic studies on Staphylococcal TSS. This criteria list is epidemiologicaly usable only, meaning that a patient can not be excluded from disease based on the absence of one of these criteria. This criteria list points that a confirmed case is someone who has fever >38.9°C, hypotension, diffuse erythroderma, desquamation (unless the patient dies before desquamation can occur), and involvement of at least three organ systems. If a patient misses one of these criteria, the case may be considered as a probable/susceptible case.[1]

TSS diagnosis can be made with the following clinical manifestations:

Laboratory Criteria for Diagnosis

If the result of the following tests become negative, it can be considered a positive criteria for TSS:

Streptococcal TSS

There is a subtle difference between Streptococcal TSS and other types. Group A Streptococcus(GAS) can be isolated in GAS-related TSS patients.

Clinical and biochemical criteria of streptococcal TSS and necrotizing fasciitis (NF).[5]

Disease Presentation Criteria Definite case Suspected case
Streptococal TSS A. Isolation of group A Streptococcus 1. From a sterile site

2. From a nonsterile body site

A1 + B(complete) A2 + B(complete)
B. Clinical signs of severity
Necrotizing fasciitis A. Clinical Criteria A (complete) + B1 A (complete) + B2

A(complete) + B3

B. Isolation of group A Streptococcus
  1. Isolation of group A Streptococcus from a normally sterile body sites
  2. Serologic confirmation of group A streptococcal infection by a 4-fold rise against:
a) streptolysin O b) DNase B
3. Histologic confirmation: Gram-positive cocci in a necrotic soft tissue infection

References

  1. Tofte RW, Williams DN (1981). "Toxic shock syndrome. Evidence of a broad clinical spectrum". JAMA. 246 (19): 2163–7. PMID 7289007.
  2. cite journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}
  3. "Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention". MMWR Recomm Rep. 46 (RR-10): 1–55. 1997. PMID 9148133.
  4. "Toxic Shock Syndrome (Other Than Streptococcal) | 2011 Case Definition".
  5. "wwwnc.cdc.gov" (PDF).


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