Toxic Shock Syndrome

Toxic Shock Syndrome is a topic covered in the 5-Minute Emergency Consult.

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  • Toxic shock syndrome (TSS) is a severe, acute life-threatening illness
  • Etiologic organisms:
    • Staphylococcus aureus, more common (TSS)
    • Group A streptococcus or GAS, less common (Streptococcal TSS or STSS)
  • S. aureus produce structurally similar toxins:
    • Toxic shock syndrome toxin (TSST-1)
    • Enterotoxin B (SEB)
    • Enterotoxin C (SEC)
  • GAS pyrogenic exotoxins:
    • Exotoxin A (SPEA)
    • Exotoxin B (SPEB)
  • Exotoxins act as superantigens causing overwhelming immune response:
    • Massive cytokine production
    • Induce fever directly at the hypothalamus or indirectly via interleukin-1 (IL-1) and tumor necrosis factor (TNF) production
    • Enhance delayed hypersensitivity
    • Suppress neutrophil migration and immunoglobulin
    • Enhance host susceptibility to endotoxins
  • Massive vasodilation occurs
    • Serum protein and fluid shifts leading to hypotension


  • Initial cases described in young healthy menstruating females due to highly absorbent tampons
    • Changes made in tampon composition to decrease incidence
  • Approximately one-half of reported TSS cases are nonmenstrual:
    • Surgical wounds
    • Postpartum wound infections
    • Mastitis
    • Septorhinoplasty
    • Sinusitis
    • Osteomyelitis
    • Arthritis
    • Burns
    • Nasal packing (nasal tampons)
    • Cutaneous and subcutaneous lesions
  • Nonmenstrual cases predominantly due to SEB and SEC producing S. aureus
  • 30–50% of healthy adults and children carry S. aureus in the nasal vestibule, vagina, rectum and/or on the skin
  • GAS infections often begin within 24–72 hr at the site of minor trauma, often without a visible in skin
  • Despite increased incidence of Methicillin-resistant S. aureus (MRSA) infections, a recent study reported MRSA only accounting for 7% of cases

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