Toxic Shock Syndrome

Basics

Description

  • Toxic shock syndrome (TSS) is a severe, acute life-threatening illness
  • Incidence is 0.8–3.4 per 100,000 in the US
  • Most commonly caused by Staph aureus, followed by Streptococcus pyogenes (group A strep)
  • May also be caused by variety of other streptococcal species
  • These organisms produce toxins that act as superantigens
  • These superantigens bypass T-cell activation pathways, resulting in a severe acute inflammatory response:
    • Massive cytokine release
    • Fever, directly at the hypothalamus or indirectly via interleukin-1 (IL-1) and tumor necrosis factor (TNF) production
    • Enhance delayed hypersensitivity reactions
    • Directly act at tissue sites causing additional local reaction
    • Massive vasodilation and cellular fluid shifts, leading to hypotension, shock, and end-organ damage
  • 30–50% mortality, worse with delayed diagnosis/treatment

Etiology

  • Classic presentation: Young female during menstrual period. This is becoming less common, and this thought may lead to missed cases:
    • Changes made in tampon composition to decrease incidence
  • ½ associated with menstruation, ½ nonmenstrual
  • Anything retained anywhere in the body can lead to TSS
  • Soft tissue infections, postsurgical infections, burns, retained foreign bodies such as nasal packing, and dialysis catheters
  • Cases noted in postpartum and postabortion patients
  • Can happen with any group A strep infection but most common with soft tissue infections (cellulitis, myositis, and necrotizing fasciitis)
  • Up to 45% of patients do not display an infectious focus
  • Important to remember these alternative causes, as it increases the index of suspicion. Early diagnosis and treatment are key for outcomes

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