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Toxic Shock Syndrome (TSS)

Medicine > Infection

Background knowledge 🧠

Definition

  • Acute, multi-system illness caused by bacterial exotoxins.
  • Characterised by sudden onset of high fever, rash, hypotension, and multi-organ dysfunction.
  • Commonly associated with Staphylococcus aureus and Streptococcus pyogenes.

Epidemiology

  • Rare condition, incidence approximately 1-2 per 100,000 population per year.
  • Higher incidence in females due to association with tampon use.
  • Can occur in any age group, including children.
  • Seasonal variation with higher cases in winter.

Aetiology and Pathophysiology

  • Caused by exotoxins produced by bacteria, acting as superantigens.
  • Superantigens activate a large number of T cells, leading to massive cytokine release.
  • Resultant systemic inflammatory response leads to shock and multi-organ failure.
  • Commonly involves TSST-1 (Toxic Shock Syndrome Toxin-1) in staphylococcal cases.
  • Streptococcal cases often involve pyrogenic exotoxins A, B, and C.

Types

  • Menstrual Toxic Shock Syndrome: Associated with tampon use.
  • Non-Menstrual Toxic Shock Syndrome: Associated with surgical wounds, burns, or skin infections.
  • Staphylococcal Toxic Shock Syndrome: Caused by Staphylococcus aureus.
  • Streptococcal Toxic Shock Syndrome: Caused by Streptococcus pyogenes.

Clinical Features 🌡️

Symptoms

  • Sudden high fever (≥39°C).
  • Chills.
  • Diffuse macular erythroderma (sunburn-like rash).
  • Myalgia.
  • Vomiting and diarrhoea.
  • Severe hypotension.
  • Malaise and confusion.
  • Headache.
  • Pharyngitis.
  • Abdominal pain.

Signs

  • Hypotension (systolic BP < 90 mmHg).
  • Diffuse erythroderma.
  • Desquamation, particularly of palms and soles, 1-2 weeks after onset.
  • Multisystem involvement: gastrointestinal, muscular, mucous membrane hyperaemia, renal, hepatic, haematologic, and CNS.
  • Altered mental state ranging from confusion to coma.
  • Oliguria or anuria.
  • Acute respiratory distress syndrome (ARDS).
  • Disseminated intravascular coagulation (DIC).

Investigations 🧪

Tests

  • Blood cultures: Identify causative organism.
  • Full blood count: Leucocytosis with a left shift.
  • Liver function tests: Elevated transaminases.
  • Renal function tests: Elevated urea and creatinine.
  • Coagulation profile: Prolonged PT and APTT, decreased platelets.
  • Serum electrolytes: Monitor for imbalances.
  • Imaging: Chest X-ray for ARDS, echocardiogram if myocarditis suspected.

Management 🥼

Management

  • Immediate resuscitation: Airway management, oxygen therapy, IV fluids for shock.
  • Antibiotic therapy: Empirical broad-spectrum antibiotics initially, then tailored based on culture results.
  • Surgical intervention: Removal of infected tampon, debridement of infected wounds.
  • IV immunoglobulin: Considered in severe cases to neutralise exotoxins.
  • Supportive care: Management of organ failure in ICU setting.
  • Monitoring: Continuous monitoring of vital signs and organ functions.

Complications

  • Multi-organ failure.
  • Acute respiratory distress syndrome (ARDS).
  • Disseminated intravascular coagulation (DIC).
  • Renal failure.
  • Myocarditis.
  • Death if not promptly treated.

Prognosis

  • Mortality rate ranges from 5-30%.
  • Early diagnosis and treatment significantly improve outcomes.
  • Prognosis worse in streptococcal TSS compared to staphylococcal TSS.
  • Long-term sequelae may include chronic renal impairment and psychological effects.

Key Points

  • Toxic shock syndrome is a medical emergency requiring immediate attention.
  • Early recognition and aggressive management are crucial for survival.
  • Preventative measures include proper tampon use and prompt treatment of skin infections.
  • Awareness of the condition’s presentation can lead to timely intervention and better outcomes.

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Infection