Toxic shock syndrome history and symptoms: Difference between revisions

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{{Toxic shock syndrome}}
{{Toxic shock syndrome}}
{{CMG}} {{AE}}{{MIR}}
{{CMG}} {{AE}}{{MIR}}
==Overview==
==Overview==
[[Toxic shock syndrome]] (TSS) is characterized by sudden onset of [[fever]], chills, [[vomiting]], [[diarrhea]], [[muscle aches]] and [[rash]]. It can rapidly progress to severe and intractable [[hypotension]] and [[Multisystem failure|multisystem dysfunction]]. [[Desquamation]], particularly on the palms and soles can occur 1-2 weeks after onset of the illness.
A positive [[History and Physical examination|history]] of tampon usage is suggestive of [[Staphylococcus|staphylococcal]] [[toxic shock syndrome]](TSS) and a positive history of recent [[Extremities|extremity]] trauma is suggestive of [[Streptococcus|Streptococcal]] TSS (the most common causes of disease). 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).


History and symptoms of patients vary based on the organism responsible for the shock.
==History==
It is necessary to obtain a detailed and thorough [[History & Symptoms|history]] from the patient to diagnose the type of [[TSS]] and determine its severeness. It provides insight into cause, precipitating factors and associated [[Comorbidity|comorbid]] conditions. Complete history will help determine the correct therapy and helps in determining the [[prognosis]]. [[Toxic shock syndrome|TSS]] patients may be [[Disorientation|disoriented]] due to [[encephalopathy]] complication therefore the patient interview may be difficult. In such cases [[History & Symptoms|history]] from the care givers or the family members may need to be obtained. Specific histories about the symptoms (duration, onset, progression), associated symptoms, and past medical history have to be obtained.


==History and Symptoms==
Specific areas of focus when obtaining a history from the patient include:
*Recent [[fever]]
*[[Tampon]] usage<ref name="pmid2122225">{{cite journal |vauthors=Wharton M, Chorba TL, Vogt RL, Morse DL, Buehler JW |title=Case definitions for public health surveillance |journal=MMWR Recomm Rep |volume=39 |issue=RR-13 |pages=1–43 |year=1990 |pmid=2122225 |doi= |url=}}</ref>
*Recent [[trauma]] history
*Generalized associated [[Symptom|symptoms]] like [[Myalgia|myalgias]] and [[weakness]]
*Recent history of [[surgery]]


=== [[Staphylococcus|Staphylococcal]] [[TSS]] ===
==General symptoms==
[[Staphylococcus|Staphylococcal]] [[Toxic shock syndrome|TSS]] can be divided into 2 major categories based on the disease cause: [[Menstrual cycle|menstrual]] and non-menstrual illness.<ref name="pmid2122225">{{cite journal |vauthors=Wharton M, Chorba TL, Vogt RL, Morse DL, Buehler JW |title=Case definitions for public health surveillance |journal=MMWR Recomm Rep |volume=39 |issue=RR-13 |pages=1–43 |year=1990 |pmid=2122225 |doi= |url=}}</ref> Although these 2 types are different from each other in the terms of cause and [[pathogenesis]], their clinical manifestations are pretty much the same.
These [[symptoms]] are common and can be found in all different causes of [[Toxic shock syndrome|TSS]]. These are usually related to the [[shock]] itself and the [[hypersensitivity]] reaction which is related to bacterial [[antigen]]:


Clinical manifestations of [[Staphylococcus|Staphylococcal]] TSS include a variety of [[Shock (medical)|shock symptoms]], and [[hypersensitivity]] that is associated with the disease:
=== Common Symptoms ===
* [[Hypotension]]: It usually happens in a rapid onset, with a [[systolic blood pressure]] of ≤90 mmHg for adults or less than fifth percentile by age for children <16 years of age. This [[hypotension]] can be unresponsive to fluid infusion even large amounts of [[isotonic]] [[intravenous fluids]] and can persist for several days.
*[[Fever]]
*Non-specific signs:
**[[Chills]]
**[[Malaise]]
**[[Sore Throat|Sore throat]]
**[[Fatigue]]
**[[Myalgia|Myalgias]]
**[[Headache]]
**[[Abdominal pain]], severe watery [[diarrhea]], [[vomiting]]
**[[Dizziness]] or [[syncope]]
*Diffuse [[erythroderma]]
*[[Edema]] of the extremities
*[[Shortness of breath]] and [[orthopnea]] (as a result of pulmonary edema and pleural effusion secondary to the sock complication)
*[[Headaches]] (as a result of [[diarrhea]] and [[renal failure]])


* [[Skin Changes|Skin manifestations]]: These manifestations are usually due to [[hypersensitivity reactions]]. they can be very variable. The initial [[erythroderma]] can involves both  mucous membranes and skin. It's main characteristics involve diffuse, red, macular rash resembling sunburn that can also involve the palms and soles.<ref name="urlTintinallis Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books">{{cite web |url=https://books.google.com/books?id=FNKLCgAAQBAJ&q=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&dq=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&hl=en&sa=X&ved=0ahUKEwjlq-LXoODTAhVF7CYKHQ3aDkoQ6AEIJzAA |title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books |format= |work= |accessdate=}}</ref> It can be fleeting and subtle. [[Conjunctiva|Conjunctival]]-[[Sclera|scleral hemorrhage]] and [[hyperemia]] of the [[vaginal]] and [[oropharyngeal]] [[mucosa]] can be found while [[mucosal]] involvement is associated with skin manifestations. Superficial [[Ulcer|ulcerations]] can also occur on the mucous membranes especially in more advanced forms of the disease. It can lead to [[petechiae]], [[vesicles]], and bullae development. [[Edema|Non-pitting edema]] can develop as a result of increases in [[interstitial fluid]]. Late-onset skin findings include [[Pruritic disorders|pruritic]] [[maculopapular]] [[rash]] and palm/soles [[desquamation]] which particularly begins 1-3 weeks after disease beginning. As a matter of late onset characteristic of [[desquamation]], it can not be used as a good diagnostic feature. Hair and nail loss may also occur in some cases one to two months after the onset of disease, with regrowth by six months.
=== Less common symptoms ===
*[[Desquamation]] of [[Palms of the hands|palms]] and [[Sole (foot)|soles]] which particularly begins 1-3 weeks after disease beginning<ref name="urlTintinallis Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books">{{cite web |url=https://books.google.com/books?id=FNKLCgAAQBAJ&q=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&dq=It%27s+main+characteristics+involve+diffuse,+red,+macular+rash+resembling+sunburn+that+can+also+involve+the+palms+and+soles.&hl=en&sa=X&ved=0ahUKEwjlq-LXoODTAhVF7CYKHQ3aDkoQ6AEIJzAA |title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books |format= |work= |accessdate=}}</ref>  
*Neuropsychologic symptoms:
**[[Confusion]]
**[[Agitation]]
**[[Memory loss]]
**[[Disorientation]]
**Poor [[concentration]] (as a result of [[Toxic shock syndrome|TSS]] complications e.g. [[encephalopathy]])<ref name="pmid2928649">{{cite journal |vauthors=Olson RD, Stevens DL, Melish ME |title=Direct effects of purified staphylococcal toxic shock syndrome toxin 1 on myocardial function of isolated rabbit atria |journal=Rev. Infect. Dis. |volume=11 Suppl 1 |issue= |pages=S313–5 |year=1989 |pmid=2928649 |doi= |url=}}</ref>
**[[Somnolence]]
**[[Irritability]]
**[[Agitation]]
**[[Hallucination|Hallucinations]]
*[[Stupor]] or [[coma]] <ref name="pmid7091958">{{cite journal |vauthors=Rosene KA, Copass MK, Kastner LS, Nolan CM, Eschenbach DA |title=Persistent neuropsychological sequelae of toxic shock syndrome |journal=Ann. Intern. Med. |volume=96 |issue=6 Pt 2 |pages=865–70 |year=1982 |pmid=7091958 |doi= |url=}}</ref>
*[[Dyspnea]] (as a result of [[pulmonary edema]] and [[pleural effusion]])
*[[Muscle cramps]] (as a result of [[metabolic disorders]] due to [[renal failure]])<ref name="pmid7282746">{{cite journal |vauthors=Chesney RW, Chesney PJ, Davis JP, Segar WE |title=Renal manifestations of the staphylococcal toxic-shock syndrome |journal=Am. J. Med. |volume=71 |issue=4 |pages=583–8 |year=1981 |pmid=7282746 |doi= |url=}}</ref>
==Specific history and symptoms==


* [[Multiorgan system failure|Multiorgan system involvement]]: All body organ systems can be involved during disease, which can lead to specific organ related symptoms. Many patients complaint of generalized [[Myalgia|myalgias]] and [[weakness]] as their primary chief complaints. In these patients, usually elevated levels of [[Creatine phosphokinase|creatine phosphokinase (CPK)]] concentration can be detected. Gastrointestinal complaints are also common, particularly [[watery diarrhea]]. Both [[Azotemia|prerenal]] and [[Renal failure|intrinsic renal failure]] can occur. [[Renal failure]] can lead to [[Metabolic Control Analysis|metabolic abnormalitie]]<nowiki/>s such as [[hypocalcemia]], [[hyponatremia]], [[hypoalbuminemia]], and [[hypophosphatemia]].<ref name="pmid7282746">{{cite journal |vauthors=Chesney RW, Chesney PJ, Davis JP, Segar WE |title=Renal manifestations of the staphylococcal toxic-shock syndrome |journal=Am. J. Med. |volume=71 |issue=4 |pages=583–8 |year=1981 |pmid=7282746 |doi= |url=}}</ref>
=== Staphylococcal TSS ===
* Tampon usage


* [[Encephalopathy]]: [[Cerebral edema]] as a complication of [[Toxic shock syndrome|TSS]] can lead to [[encephalopathy]] which is fatal and manifested by [[disorientation]], [[confusion]], or [[Seizure activity|seizure]] activity<ref name="pmid3722844">{{cite journal |vauthors=Barrett JA, Graham DR |title=Toxic shock syndrome presenting as encephalopathy |journal=J. Infect. |volume=12 aissue=3 |pages=276–8 |year=1986 |pmid=3722844 |doi= |url=}}</ref>,<ref name="pmid3362331">{{cite journal |vauthors=Smith DB, Gulinson J |title=Fatal cerebral edema complicating toxic shock syndrome |journal=Neurosurgery |volume=22 |issue=3 |pages=598–9 |year=1988 |pmid=3362331 |doi= |url=}}</ref>. Other [[Central nervous system|central nervous system (CNS)]] findings may be present rarely in patients for instance persistent [[neuropsychological]] sequels can develop such as [[headaches]], [[memory loss]], and poor [[concentration]] <ref name="pmid7091958">{{cite journal |vauthors=Rosene KA, Copass MK, Kastner LS, Nolan CM, Eschenbach DA |title=Persistent neuropsychological sequelae of toxic shock syndrome |journal=Ann. Intern. Med. |volume=96 |issue=6 Pt 2 |pages=865–70 |year=1982 |pmid=7091958 |doi= |url=}}</ref>. Other symptoms that can be found in patients with [[encephalopathy]] due to TSS include [[Pleural effusion|pleural effusions]] and [[pulmonary edema]], [[cardiac dysfunction]], [[hepatic failure]], and [[CBC|hematologic abnormalities]], especially [[anemia]] and [[thrombocytopenia]].<ref name="pmid2928649">{{cite journal |vauthors=Olson RD, Stevens DL, Melish ME |title=Direct effects of purified staphylococcal toxic shock syndrome toxin 1 on myocardial function of isolated rabbit atria |journal=Rev. Infect. Dis. |volume=11 Suppl 1 |issue= |pages=S313–5 |year=1989 |pmid=2928649 |doi= |url=}}</ref>
=== Streptococcal TSS ===
* History of [[Skin lesions|cutaneous lesion]], specially with local [[blunt trauma]] injury and [[Penetrating wound|penetrating tissue]] trauma<ref name="pmid2659990">{{cite journal |vauthors=Stevens DL, Tanner MH, Winship J, Swarts R, Ries KM, Schlievert PM, Kaplan E |title=Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A |journal=N. Engl. J. Med. |volume=321 |issue=1 |pages=1–7 |year=1989 |pmid=2659990 |doi=10.1056/NEJM198907063210101 |url=}}</ref><ref name="pmid3890787">{{cite journal |vauthors=Adams EM, Gudmundsson S, Yocum DE, Haselby RC, Craig WA, Sundstrom WR |title=Streptococcal myositis |journal=Arch. Intern. Med. |volume=145 |issue=6 |pages=1020–3 |year=1985 |pmid=3890787 |doi= |url=}}</ref>


=== [[Streptococcus|Streptococcal]] [[Toxic shock syndrome|TSS]] ===
* [[Cyanosis]]
[[Streptococcus|Streptococcal]] [[Toxic shock syndrome|TSS]] may occur with infection at any site, but most often occurs in association with infection of a [[Skin lesions|cutaneous lesion]], specially with local [[blunt trauma]] injury and [[Penetrating wound|penetrating tissue]] trauma that can lead to [[Necrotizing Fasciitis|necrotizing fasciitis]] (NF). [[Necrotising fasciitis|NF]] mostly occurs in the [[lower limb]], followed by the [[upper limb]]. Although the invasive nature of disease is well known, most of the time origin of entry and source of infection can not be identified that lead to a significant problem<ref name="pmid2659990">{{cite journal |vauthors=Stevens DL, Tanner MH, Winship J, Swarts R, Ries KM, Schlievert PM, Kaplan E |title=Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A |journal=N. Engl. J. Med. |volume=321 |issue=1 |pages=1–7 |year=1989 |pmid=2659990 |doi=10.1056/NEJM198907063210101 |url=}}</ref>,<ref name="pmid3890787">{{cite journal |vauthors=Adams EM, Gudmundsson S, Yocum DE, Haselby RC, Craig WA, Sundstrom WR |title=Streptococcal myositis |journal=Arch. Intern. Med. |volume=145 |issue=6 |pages=1020–3 |year=1985 |pmid=3890787 |doi= |url=}}</ref>. The symptoms and signs of [[Toxic shock syndrome|TSS]] develop rapidly, usually in otherwise healthy individuals. The disease should be diagnosed based on the clinical findings primarily. In most cases of [[Necrotizing fasciitis|NF]]-related [[Toxic shock syndrome|TSS]] fatality rate may exceed 50%<ref name="pmid9236481">{{cite journal |vauthors=Kaul R, McGeer A, Low DE, Green K, Schwartz B |title=Population-based surveillance for group A streptococcal necrotizing fasciitis: Clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario Group A Streptococcal Study |journal=Am. J. Med. |volume=103 |issue=1 |pages=18–24 |year=1997 |pmid=9236481 |doi= |url=}}</ref>.
* Bullae in [[extremities]] with a history of trauma<ref name="pmid17697787">{{cite journal |vauthors=Nuwayhid ZB, Aronoff DM, Mulla ZD |title=Blunt trauma as a risk factor for group A streptococcal necrotizing fasciitis |journal=Ann Epidemiol |volume=17 |issue=11 |pages=878–81 |year=2007 |pmid=17697787 |pmc=4029051 |doi=10.1016/j.annepidem.2007.05.011 |url=}}</ref>


Patients with [[Streptococcal infections|GAS]]-associated [[Necrotizing fasciitis|NF]] may present with non-specific signs of disease when they primarily administered. This can make it difficult to differentiate their disease from a simple [[cellulitis]]. [[Necrotizing fasciitis|NF]] can cause severe pain and local [[tenderness]] which is disproportionate to other physical findings; this can be used as a clinical hallmark for differentiating [[Necrotizing fasciitis|NF]] from other superficial infections. Late signs that present themselves with disease progression include [[Edema|tense edema]] and bullae development that seem bluish. Edema and bluish bullae indicate significant [[Necrosis|tissue necrosis]] and severity of the disease.<ref name="pmid3890787">{{cite journal |vauthors=Adams EM, Gudmundsson S, Yocum DE, Haselby RC, Craig WA, Sundstrom WR |title=Streptococcal myositis |journal=Arch. Intern. Med. |volume=145 |issue=6 |pages=1020–3 |year=1985 |pmid=3890787 |doi= |url=}}</ref>,<ref name="pmid17697787">{{cite journal |vauthors=Nuwayhid ZB, Aronoff DM, Mulla ZD |title=Blunt trauma as a risk factor for group A streptococcal necrotizing fasciitis |journal=Ann Epidemiol |volume=17 |issue=11 |pages=878–81 |year=2007 |pmid=17697787 |pmc=4029051 |doi=10.1016/j.annepidem.2007.05.011 |url=}}</ref>.
=== Clostridium sordellii TSS ===
* Flu like symptoms
* History of [[pneumonia]]<ref name="pmid17083018">{{cite journal |vauthors=Aldape MJ, Bryant AE, Stevens DL |title=Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment |journal=Clin. Infect. Dis. |volume=43 |issue=11 |pages=1436–46 |year=2006 |pmid=17083018 |doi=10.1086/508866 |url=}}</ref>
* History of surgery
* [[Surgical site infection]]<ref name="pmid17577829">{{cite journal |vauthors=Foroulis CN, Gerogianni I, Kouritas VK, Karestsi E, Klapsa D, Gourgoulianis K, Petinaki E |title=Direct detection of Clostridium sordellii in pleural fluid of a patient with pneumonic empyema by a broad-range 16S rRNA PCR |journal=Scand. J. Infect. Dis. |volume=39 |issue=6-7 |pages=617–9 |year=2007 |pmid=17577829 |doi=10.1080/00365540601105798 |url=}}</ref><ref name="pmid1457666">{{cite journal |vauthors=Spera RV, Kaplan MH, Allen SL |title=Clostridium sordellii bacteremia: case report and review |journal=Clin. Infect. Dis. |volume=15 |issue=6 |pages=950–4 |year=1992 |pmid=1457666 |doi= |url=}}</ref>


[[Toxic shock syndrome|Toxic shock syndrom]]<nowiki/>e signs and symptoms are exactly like [[Staphylococcal]] [[Toxic shock syndrome|TSS]] and include [[fever]], [[hypotension]], and skin manifestations (as mentioned before). Also non-specific signs like [[chills]], [[malaise]], [[Sore Throat|sore throat]], [[fatigue]], [[Myalgia|myalgias]], [[headache]], [[abdominal pain]], [[diarrhea]], [[vomiting]] and [[Orthostatic hypotension|orthostatic]] [[hypotension]] with [[dizziness]] or [[syncope]] may be seen.


=== [[Clostridium|Clostridium sordellii]] [[Toxic shock syndrome|TSS]] ===
===Various Causes of TSS and their Symptoms===
This is a rare cause of [[Toxic shock syndrome|TSS]] but maybe the most dangerous cause with a rapid onset. There are a variety of symptoms include [[skin infection]], [[bacteremia]], and organ specific infections such as [[pneumonia]], [[empyema]], [[endocarditis]], [[septic arthritis]], and [[surgical site infection]]<ref name="pmid17577829">{{cite journal |vauthors=Foroulis CN, Gerogianni I, Kouritas VK, Karestsi E, Klapsa D, Gourgoulianis K, Petinaki E |title=Direct detection of Clostridium sordellii in pleural fluid of a patient with pneumonic empyema by a broad-range 16S rRNA PCR |journal=Scand. J. Infect. Dis. |volume=39 |issue=6-7 |pages=617–9 |year=2007 |pmid=17577829 |doi=10.1080/00365540601105798 |url=}}</ref>,<ref name="pmid1457666">{{cite journal |vauthors=Spera RV, Kaplan MH, Allen SL |title=Clostridium sordellii bacteremia: case report and review |journal=Clin. Infect. Dis. |volume=15 |issue=6 |pages=950–4 |year=1992 |pmid=1457666 |doi= |url=}}</ref>, <ref name="pmid2026891">{{cite journal |vauthors=Buchman AL, Ponsillo M, Nagami PH |title=Empyema caused by Clostridium sordellii, a rare form of pleuropulmonary disease |journal=J. Infect. |volume=22 |issue=2 |pages=171–4 |year=1991 |pmid=2026891 |doi= |url=}}</ref>. C. sordellii toxic shock is characterized by rapid occurrence of severe disease symptoms with shock; in these cases TSS mostly occurs in previously healthy individuals. 2801850. The clinical presentation generally consists of specific infection related manifestations including profound [[leukocytosis]], [[hemoconcentration]], [[edema]], effusions,and followed by [[multiorgan failure]] and [[shock]].
 
Disease primary symptoms include nonspecific symptoms that may be misdiagnosed with [[viral infections]] like flu and may include [[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]], [[lethargy]], [[influenza-like symptoms]], and [[abdominal tenderness]]<ref name="pmid15516429">{{cite journal |vauthors=Wiebe E, Guilbert E, Jacot F, Shannon C, Winikoff B |title=A fatal case of Clostridium sordellii septic shock syndrome associated with medical abortion |journal=Obstet Gynecol |volume=104 |issue=5 Pt 2 |pages=1142–4 |year=2004 |pmid=15516429 |doi=10.1097/01.AOG.0000142738.68439.9e |url=}}</ref>,<ref name="pmid9155682">{{cite journal |vauthors=Bitti A, Mastrantonio P, Spigaglia P, Urru G, Spano AI, Moretti G, Cherchi GB |title=A fatal postpartum Clostridium sordellii associated toxic shock syndrome |journal=J. Clin. Pathol. |volume=50 |issue=3 |pages=259–60 |year=1997 |pmid=9155682 |pmc=499826 |doi= |url=}}</ref>.
 
Disease progression to the [[shock]] and severe symptoms occurs within hours. The [[nature]] of disease which starts with nonspecific symptoms and its rapid progression toward shock make in really hard to diagnose it in early stages; that may be the reason of disease's high [[mortality]] <ref name="pmid17083018">{{cite journal |vauthors=Aldape MJ, Bryant AE, Stevens DL |title=Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment |journal=Clin. Infect. Dis. |volume=43 |issue=11 |pages=1436–46 |year=2006 |pmid=17083018 |doi=10.1086/508866 |url=}}</ref>. 
 
* diagnostic clues based on signs and symptoms of disease
{| class="wikitable"
{| class="wikitable"
!
! align="center" style="background:#4479BA; color: #FFFFFF;" |
!diagnostic clues in C. sordellii
! align="center" style="background:#4479BA; color: #FFFFFF;" |Type
!causes
! align="center" style="background:#4479BA; color: #FFFFFF;" |Symptoms
!
|-
|-
!generalized symptoms
| rowspan="2" align="center" style="background:#DCDCDC;"|[[Staphylococcus|Staphylococcal]] [[Toxic shock syndrome|TSS]]
|[[hypotension]]
|Menstural


[[tachycardia]]
| rowspan="2" |[[Skin Changes|Skin manifestations]]: [[Erythroderma]]


absence of fever
Conjunctival-scleral hemorrhage
|generalized toxic-mediated changes
|
|-
!diffuse [[edema]]
|generalized
|rapid development of generalized and massive tissue edema due to toxin-mediated changes and increase in [[vascular]] [[permeability]]
|
|-
!effusion
|[[Pleural effusion|pleural]]


[[Pericardial effusion|pericardial]]
Hyperemia of the vaginal


[[Peritoneum|peritonea]]<nowiki/>l
Hyperemia of oropharyngeal mucosa
|due to [[capillary]] leak from toxin-mediated changes in the vascular endothelium and ahypoalbuminemia
|-
|
|Non-menstural
|-
|-
!laboratory changes
| align="center" style="background:#DCDCDC;"|[[Streptococcus|Streptococcal]] [[Toxic shock syndrome|TSS]]
|[[leukocytosis]] [[hemoconcentration]]  
|[[Necrotizing Fasciitis|GAS-related NF]]
|
|
* Profound [[leukocytosis]] ([[leukemoid reaction]]) consisting of white blood cell (WBC) count >50,000 cells/microL, which can increase to 200,000 cells/microL within 48 hours
* Skin and [[Skin lesions|cutaneous lesion]]<nowiki/>s:
* An increased percentage of mature and immature [[Neutrophil|neutrophils]] and increased absolute numbers of [[Lymphocyte|lymphocytes]] and [[Monocyte|monocytes]]
** [[Necrotizing Fasciitis|Necrotizing fasciitis]] (NF)
* [[Leukemoid reaction]] is highly predictive of mortality
** [[Edema|Tense edema]]
* [[Hematocrit]] levels up to 80 percent have been reported
** Bluish bullae with disease progression
|}
* TSS different causes and their symptoms
{| class="wikitable"
!
!type
!symptoms
|-
|[[Staphylococcus|Staphylococcal]] [[Toxic shock syndrome|TSS]]
|menstural
non-menstural
|[[hypotension]]


[[Skin Changes|Skin manifestations]]: [[erythroderma]]
* General Shock Signs:  
 
** [[Fever]]
Conjunctival-scleral hemorrhage and hyperemia of the vaginal and oropharyngeal mucosa
** [[Hypotension]]
|-
** [[Chills]]
|[[Streptococcus|Streptococcal]] [[Toxic shock syndrome|TSS]]
** [[Malaise]]
|[[Necrotizing Fasciitis|GAS-related NF]]
** [[Sore Throat|Sore throat]]
|skin and [[Skin lesions|cutaneous lesion]]<nowiki/>s:
** [[Fatigue]]
* [[Necrotizing Fasciitis|necrotizing fasciitis]] (NF)
** [[Myalgia|Myalgias]]
* [[Edema|tense edema]] and bluish bullae with disease progression
** [[Headache]]
General Shock Signs: [[fever]], [[hypotension]], [[chills]], [[malaise]], [[Sore Throat|sore throat]], [[fatigue]], [[Myalgia|myalgias]], [[headache]], [[abdominal pain]], [[diarrhea]], [[vomiting]] and [[Orthostatic hypotension|orthostatic]] [[hypotension]] with [[dizziness]] or [[syncope]]  
** [[Abdominal pain]]
** [[Diarrhea]]
** [[Vomiting]]
** [[Orthostatic hypotension|Orthostatic]] [[hypotension]]
** [[Dizziness]] or [[syncope]]
|-
|-
|[[Clostridium|Clostridium sordellii]] [[Toxic shock syndrome|TSS]]
| align="center" style="background:#DCDCDC;"|[[Clostridium|Clostridium sordellii]] [[Toxic shock syndrome|TSS]]
| -
| -
|nonspecific primary symptoms that may be misdiagnosed with [[viral infections]] like [[flu]] ([[Nausea and vomiting|nausea]], [[Nausea and vomiting|vomiting]], [[lethargy]], [[influenza-like symptoms]], and [[abdominal tenderness]])
|
* Nonspecific primary symptoms that may be misdiagnosed with [[viral infections]] like [[flu]]:
** [[Nausea and vomiting|Nausea]]
** [[Nausea and vomiting|Vomiting]]
** [[Lethargy]]
** [[Influenza-like symptoms]]
** [[Abdominal tenderness]])


[[skin infection]], [[bacteremia]], and organ specific infections such as [[pneumonia]], [[empyema]], [[endocarditis]], [[septic arthritis]], and [[surgical site infection]]
* [[Skin infection]], [[bacteremia]], and organ specific infections:
** [[Pneumonia]]
** [[Empyema]]
** [[Endocarditis]]
** [[Septic arthritis]]
** [[Surgical site infection]]
|}
|}


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[[Category:Disease]]
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[[Category:Syndromes]]
[[Category:Syndromes]]
[[Category:Emergency mdicine]]
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[[Category:Infectious disease]]

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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

A positive history of tampon usage is suggestive of staphylococcal toxic shock syndrome(TSS) and a positive history of recent extremity trauma is suggestive of Streptococcal TSS (the most common causes of disease). 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).

History

It is necessary to obtain a detailed and thorough history from the patient to diagnose the type of TSS and determine its severeness. It provides insight into cause, precipitating factors and associated comorbid conditions. Complete history will help determine the correct therapy and helps in determining the prognosis. TSS patients may be disoriented due to encephalopathy complication therefore the patient interview may be difficult. In such cases history from the care givers or the family members may need to be obtained. Specific histories about the symptoms (duration, onset, progression), associated symptoms, and past medical history have to be obtained.

Specific areas of focus when obtaining a history from the patient include:

General symptoms

These symptoms are common and can be found in all different causes of TSS. These are usually related to the shock itself and the hypersensitivity reaction which is related to bacterial antigen:

Common Symptoms

Less common symptoms

Specific history and symptoms

Staphylococcal TSS

  • Tampon usage

Streptococcal TSS

Clostridium sordellii TSS


Various Causes of TSS and their Symptoms

Type Symptoms
Staphylococcal TSS Menstural Skin manifestations: Erythroderma

Conjunctival-scleral hemorrhage

Hyperemia of the vaginal

Hyperemia of oropharyngeal mucosa

Non-menstural
Streptococcal TSS GAS-related NF
Clostridium sordellii TSS -

References

  1. ↑ Wharton M, Chorba TL, Vogt RL, Morse DL, Buehler JW (1990). "Case definitions for public health surveillance". MMWR Recomm Rep. 39 (RR-13): 1–43. PMID 2122225.
  2. ↑ "Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th edition - Judith Tintinalli, J. Stapczynski, O. John Ma, David M. Cline, Garth Meckler - Google Books".
  3. ↑ Olson RD, Stevens DL, Melish ME (1989). "Direct effects of purified staphylococcal toxic shock syndrome toxin 1 on myocardial function of isolated rabbit atria". Rev. Infect. Dis. 11 Suppl 1: S313–5. PMID 2928649.
  4. ↑ Rosene KA, Copass MK, Kastner LS, Nolan CM, Eschenbach DA (1982). "Persistent neuropsychological sequelae of toxic shock syndrome". Ann. Intern. Med. 96 (6 Pt 2): 865–70. PMID 7091958.
  5. ↑ Chesney RW, Chesney PJ, Davis JP, Segar WE (1981). "Renal manifestations of the staphylococcal toxic-shock syndrome". Am. J. Med. 71 (4): 583–8. PMID 7282746.
  6. ↑ Stevens DL, Tanner MH, Winship J, Swarts R, Ries KM, Schlievert PM, Kaplan E (1989). "Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A". N. Engl. J. Med. 321 (1): 1–7. doi:10.1056/NEJM198907063210101. PMID 2659990.
  7. ↑ Adams EM, Gudmundsson S, Yocum DE, Haselby RC, Craig WA, Sundstrom WR (1985). "Streptococcal myositis". Arch. Intern. Med. 145 (6): 1020–3. PMID 3890787.
  8. ↑ Nuwayhid ZB, Aronoff DM, Mulla ZD (2007). "Blunt trauma as a risk factor for group A streptococcal necrotizing fasciitis". Ann Epidemiol. 17 (11): 878–81. doi:10.1016/j.annepidem.2007.05.011. PMC 4029051. PMID 17697787.
  9. ↑ Aldape MJ, Bryant AE, Stevens DL (2006). "Clostridium sordellii infection: epidemiology, clinical findings, and current perspectives on diagnosis and treatment". Clin. Infect. Dis. 43 (11): 1436–46. doi:10.1086/508866. PMID 17083018.
  10. ↑ Foroulis CN, Gerogianni I, Kouritas VK, Karestsi E, Klapsa D, Gourgoulianis K, Petinaki E (2007). "Direct detection of Clostridium sordellii in pleural fluid of a patient with pneumonic empyema by a broad-range 16S rRNA PCR". Scand. J. Infect. Dis. 39 (6–7): 617–9. doi:10.1080/00365540601105798. PMID 17577829.
  11. ↑ Spera RV, Kaplan MH, Allen SL (1992). "Clostridium sordellii bacteremia: case report and review". Clin. Infect. Dis. 15 (6): 950–4. PMID 1457666.


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