Toxic shock syndrome overview

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Toxic Shock Syndrome from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

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Treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Toxic shock syndrome 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 and varicella zoster virus. The syndrome consists of sudden onset of fever, chills, vomiting, diarrhea, muscle aches 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 sordelliInfluenza 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.

Differentiating Toxic Shock Syndrome from other Diseases

Toxic shock syndrome 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

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 multiorgan system failure with serious morbidity and mortality. Appropriate treatment leads to full recovery of the patient.

Diagnosis

Diagnostic Criteria

History and Symptoms

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 dysfunction. Desquamation, particularly on the palms and soles can occur 1-2 weeks after onset of the illness.

Physical Examination

Laboratory Findings

X-Rays

CT Scan

MRI

Other Imaging Studies

Other Diagnostic Studies

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

References


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