Toxic shock syndrome history and symptoms: Difference between revisions

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{{Toxic shock syndrome}}
{{Toxic shock syndrome}}
{{CMG}} {{AE}}{{MIR}}
==Overview==
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).


{{CMG}}
==History==
==Overview==
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.
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.
 
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]]
 
==General symptoms==
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]]:
 
=== Common Symptoms ===
*[[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]])
 
=== 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==
 
=== Staphylococcal TSS ===
* Tampon usage
 
=== 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>
 
* [[Cyanosis]]
* 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>


==History and Symptoms==
=== 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>


=== [[Staphylococcus|Staphylococcal]] [[TSS]] ===
Staphylococcal TSS can be devided into 2 major categories based on the disease cause: menstrual and nonmenstrual 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>


clinical manifestations of TSS include a variety of shock symptoms, and hypersensitivity that is associated with the disease:  
===Various Causes of TSS and their 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.
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" |
! align="center" style="background:#4479BA; color: #FFFFFF;" |Type
! align="center" style="background:#4479BA; color: #FFFFFF;" |Symptoms
|-
| rowspan="2" align="center" style="background:#DCDCDC;"|[[Staphylococcus|Staphylococcal]] [[Toxic shock syndrome|TSS]]
|Menstural


* [[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. Conjunctival-scleral hemorrhage and hyperemia of the vaginal and oropharyngeal mucosa can be found while mucosal involvement is associated with skin manifestations. Superficial 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. Non-pitting edema can develop as a result of increases in interstitial fluid. Late-onset skin findings include pruritic maculopapular rash and palm/soles desquamation which particularly begins 1-3 weeks after disease beginning. as a matter of late onset characteristic of dequamation, 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.
| rowspan="2" |[[Skin Changes|Skin manifestations]]: [[Erythroderma]]


* 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 myalgias and weakness as their primary chief complaints. In these patients, usually elevated levels of creatine phosphokinase (CPK) concentration can be detected. Gastrointestinal complaints are also common, particularly watery diarrhea. Both prerenal and intrinsic renal failure can occur and are often accompanied by other metabolic abnormalities including hyponatremia, hypoalbuminemia, hypocalcemia, and hypophosphatemia.
Conjunctival-scleral hemorrhage


* Encephalopathy, manifested by disorientation, confusion, or seizure activity, can be a presenting symptom of TSS [59] and is probably due to cerebral edema [60]. Other central nervous system (CNS) findings have been reported in some patients. Persistent neuropsychological sequelae can develop such as headaches, memory loss, and poor concentration [61]. Other findings include pulmonary edema and pleural effusions, depression of myocardial function [62], hepatic dysfunction, and hematologic abnormalities, such as anemia and thrombocytopenia.
Hyperemia of the vaginal


* Menstrual versus nonmenstrual cases — The clinical presentations of menstrual and nonmenstrual TSS are similar. In one small study, nonmenstrual TSS was associated with earlier onset of rash and fever, more pronounced renal and CNS complications, and less musculoskeletal involvement [63]. Surgical wound sites and cutaneous infections that harbor toxin-producing S. aureus are frequently benign, appearing without obvious purulence [29,63].
Hyperemia of oropharyngeal mucosa
|-
|Non-menstural
|-
| align="center" style="background:#DCDCDC;"|[[Streptococcus|Streptococcal]] [[Toxic shock syndrome|TSS]]
|[[Necrotizing Fasciitis|GAS-related NF]]
|
* Skin and [[Skin lesions|cutaneous lesion]]<nowiki/>s:
** [[Necrotizing Fasciitis|Necrotizing fasciitis]] (NF)
** [[Edema|Tense edema]]
** Bluish bullae with disease progression


In contrast to STSS, Staphylococcus aureus is only rarely (5%) recovered from blood cultures.
* General Shock Signs:
** [[Fever]]
** [[Hypotension]]
** [[Chills]]
** [[Malaise]]
** [[Sore Throat|Sore throat]]
** [[Fatigue]]
** [[Myalgia|Myalgias]]
** [[Headache]]
** [[Abdominal pain]]
** [[Diarrhea]]
** [[Vomiting]]
** [[Orthostatic hypotension|Orthostatic]] [[hypotension]]
** [[Dizziness]] or [[syncope]]
|-
| 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]]
** [[Abdominal tenderness]])


The isolation of S. aureus is not required for the diagnosis of staphylococcal TSS, but isolation of GAS is absolutely necessary for the diagnosis of group A streptococcal causes of TSS
* [[Skin infection]], [[bacteremia]], and organ specific infections:
** [[Pneumonia]]
** [[Empyema]]
** [[Endocarditis]]
** [[Septic arthritis]]
** [[Surgical site infection]]
|}


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

Latest revision as of 00:27, 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

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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