Toxic Shock Syndrome (TSS)

Onset of toxic shock syndrome is sudden, with

Staphylococcal TSS is likely to cause vomiting, diarrhea, myalgia, elevated creatine kinase, mucositis, hepatic damage, thrombocytopenia, and confusion. The staphylococcal TSS rash is more likely to desquamate, particularly on the palms and soles, between 3 and 7 days after onset.

Streptococcal TSS commonly causes acute respiratory distress syndrome (in about 55% of patients), coagulopathy, and hepatic damage and is more likely to cause high fever, malaise, tachycardia, tachypnea, and, at the site of a soft-tissue infection, severe pain.

Renal impairment is frequent and common in both types of TSS.

TSS may progress within 48 hours to syncope, tissue necrosis, shock, disseminated coagulation, multisystem organ failure, and death. Less severe cases of staphylococcal TSS are fairly common.

Diagnosis of toxic shock syndrome (TSS) is made clinically and by isolating the organism from blood cultures (for Streptococcus) or from the local site.

Specimens for culture should be taken from any lesions, the nose (for staphylococci), throat (for streptococci), vagina (for both), and blood.

MRI or CT of soft tissue is helpful in localizing sites of infection.

Continuous monitoring of renal, hepatic, bone marrow, and cardiopulmonary function is necessary.

Patients suspected of having TSS should be hospitalized immediately and treated intensively. Tampons, diaphragms, and other foreign bodies should be removed at once.

Suspected primary sites should be decontaminated thoroughly. Decontamination includes

Fluids and electrolytes are replaced to prevent or treat hypovolemia, hypotension, and shock. Because fluid loss into tissues can occur throughout the body (because of systemic capillary leak syndrome and hypoalbuminemia), shock may be profound and resistant. Aggressive fluid resuscitation and circulatory, ventilatory, and/or hemodialysis support are sometimes required.

Obvious infections should be treated with antibiotics (for indications and doses, see table ). Pending culture results, clindamycin or linezolid (to suppress toxin production) plus vancomycin, daptomycin, linezolid, or ceftaroline—empiric choices that cover the most likely etiologic organisms—should be used. If a pathogen is isolated on culture, the antibiotic regimen is adjusted as needed, as for the following:

Antibiotics given during the acute illness may eradicate pathogen foci and prevent recurrences. Passive immunization to TSS toxins with IV immune globulin (2 g/kg, followed by 0.4 g/kg daily for up to 5 days) has been helpful in severe cases of both types of TSS and lasts for weeks, but the disease may not induce active immunity, so recurrences are possible.

If a test for seroconversion of the serum antibody responses to TSST-1 in acute- and convalescent-phase paired sera is negative, women who have had staphylococcal TSS should probably refrain from using tampons and menstrual cups, cervical caps, contraceptive sponges, intrauterine devices, diaphragms, and pessaries. Advising all women, regardless of TSST-1 antibody status, to change tampons frequently or use napkins instead and to avoid hyperabsorbent tampons seems prudent.