Sudden development of rash in palms and soles accompanied by fever, changes in mental status with renal or respiratory failure indicates onset of TSS. In addition, affected individuals would also exhibit signs of diarrhea, nausea, headache, low blood pressure, seizures, muscle aches, vomiting and development of redness in the eyes, throat and mouth.

The rash that develops often appears like sun burns followed by skin peeling and occurs after a period of 1 to 2 weeks. The common sites of rash development are the palms and area beneath the feet.

Signs and symptoms of TSS often develop suddenly indicating quick and prompt medical intervention. Failure to initiate immediate treatment can cause debilitating complications to set in [7].

• Fever

  Fever — Temperature ≥ 38.9°C (102°F) 2. Rash — Diffuse macular erythroderma 3. Desquamation 1–2 weeks after onset of illness, particularly of palms and soles 4. [lifeinthefastlane.com]

  TSS should be considered strongly in any menstruating women with fever and in any individual with fever and shock. Screening diagnostic criteria include scarlatiniform erythroderma, pharyngitis, nonpurulent conjunctivitis, and fever. [glowm.com]

  Tss characterised by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. [icd9data.com]

  On day 3, she exhibited a fever, generalized rash and multiple organ failure. She was diagnosed with toxic shock syndrome after burns. [ncbi.nlm.nih.gov]

• High Fever

  Tss characterised by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. [icd9data.com]

  Warning signs of TSS include: sudden high fever (usually 102ºF or more) accompanied by vomiting and/or diarrhea, fainting or near-fainting when standing up and dizziness or a sunburn-like rash. [web.archive.org]

  This report describes a previously healthy young man with streptococcal toxic shock syndrome who presented with fatigue, high fever, and suspected extensive streptococcal tonsillopharyngitis. [ncbi.nlm.nih.gov]

  Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. [medical-dictionary.thefreedictionary.com]

• Malaise

  He became sick two days earlier with malaise, chills and shivering. On admission he was hypotensive, anuric, with erythematous rash on his face, neck and chest, with acute renal failure and elevated creatine phosphokinase level. [ncbi.nlm.nih.gov]

  TSS resulting from infection with the bacterium Staphylococcus aureus typically manifests in otherwise healthy individuals via signs and symptoms including high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress [en.wikipedia.org]

  These mild symptoms may include low-grade fever, muscle aches, chills, and malaise (a feeling of general discomfort, uneasiness, or ill health). [emedicinehealth.com]

• Vomiting

  Laboratory findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting [icd9data.com]

  […] by, last update March 17, 2019 aka Microbial Mystery 004 A 15 year-old female presents with fever (T39.0), vomiting and diarrhoea, widespread muscle aches and a confluent erythematous macular rash resembling sunburn all over her body. [lifeinthefastlane.com]

  This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. [ncbi.nlm.nih.gov]

• Diarrhea

  and myalgia, followed by hypotension and in severe cases, shock; a sunburn-like rash with peeling of the skin, especially of the palms and soles, occurs during the acute phase Syndrome characterized by high fever, vomiting, diarrhea, confusion, and [icd9data.com]

  Although diarrhea is characteristic of food poisoning, the diarrhea accompanying TSS is a profuse secretory diarrhea and of several days duration. [scielo.br]

  This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. [ncbi.nlm.nih.gov]

  Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. [medical-dictionary.thefreedictionary.com]

• Nausea

  This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. [ncbi.nlm.nih.gov]

  […] vomiting confusion sleepiness Signs of kidney failure may include: fatigue weakness nausea and vomiting muscle cramps hiccups persistent itching chest pain shortness of breath high blood pressure sleep problems swelling in the feet and ankles problems [healthline.com]

• Abdominal Pain

  A 32-year-old primigravida at 21 weeks of gestation was taken to our hospital with acute severe abdominal pain following fever. On admission the fetus was found to be dead, and intrauterine fetal demise due to placental abruption was suspected. [ncbi.nlm.nih.gov]

  For example, pain in the muscles, abdominal pain (such as after childbirth) or cough" When to seek medical advice If you develop a sudden fever and one or more of the other symptoms, the NHS says it is still extremely unlikely that you have TSS. [mirror.co.uk]

• Strawberry Tongue

  Redness of the eyes, the lips, and the tongue [strawberry tongue] may also occur. The rash also can occur on the palms and soles of the feet .) [emedicinehealth.com]

  This can be associated with hyperemia of the pharynx and conjunctiva, possibly with a “strawberry tongue” appearance (below). [emcrit.org]

  About 25% of patients will have a strawberry tongue. In menstruating patients, the cervicovaginal mucous membranes will also be intensely red. [scielo.br]

• Hypotension

  She is persistently hypotensive (BP 85/35 mmHg) despite 2L of crystalloid fluid resuscitation. [lifeinthefastlane.com]

  Toxic shock syndrome (TSS) is an acute toxin-mediated infectious syndrome characterized by fever, hypotension, desquamation, and multiorgan involvement. [ncbi.nlm.nih.gov]

  Clinically, both present with acute onset of hypotension and multiorgan failure with a distributive shock physiology. [errolozdalga.com]

  Tss characterised by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. [icd9data.com]

  The physical findings for staph TSS are fever, tachycardia, hypotension, sun burn type rash (90%), and altered mental status. [clinicaladvisor.com]

• Tachycardia

  The physical findings for staph TSS are fever, tachycardia, hypotension, sun burn type rash (90%), and altered mental status. [clinicaladvisor.com]

  He initially suffered minor trauma playing basketball, and later presented to his pediatrician with fever, vomiting, severe leg pain, tachypnea, and tachycardia. Initially he was misdiagnosed as having gastroenteritis. [emcrit.org]

  Tachycardia, markedly elevated temperatures, and hypotension which is initially orthostatic are present. [scielo.br]

  Altered sensorium with disorientation, somnolence, or agitation is common. 28 In some patients, however, onset is gradual, and the characteristic rash is not seen for several days. 2 Examination usually reveals a patient with fever, tachycardia, low or [glowm.com]

  Test characteristics of an automated age- and temperature-adjusted tachycardia alert in pediatric septic shock. Pediatr Emerg Care. 2012 Sep. 28(9):889-94. [Medline]. Dauwalder O, Venet F, Javouhey E, Badiou C, Gillet Y, Guignant C, et al. [emedicine.com]

• Refractory Shock

  Despite conventional treatment, the patient developed refractory shock, which was immediately improved with PMX-DHP. [ncbi.nlm.nih.gov]

• Conjunctival Injection

  Over the course of the next 24 to 48 h, generalized edema of face, hands and feet, arthralgias, particularly of the wrists, knees, ankles, fingers, and toes, the erythroderma, conjunctival injection, cough, dizziness and syncope, incontinence, and oliguria [scielo.br]

• Myalgia

  […] tool=bestpractice.com Although the presenting signs and symptoms can be non-specific (e.g., fever, chills, myalgias, headache), the course of the disease is precipitous, and shock and multi-organ system failure occur early in the course of the disease [bestpractice.bmj.com]

  […] findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting, diarrhea, and myalgia [icd9data.com]

  […] equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years Multisystem involvement (three or more of the following organ systems): Gastrointestinal: vomiting or diarrhea at onset of illness Muscular: severe myalgia [wwwn.cdc.gov]

  The gastrointestinal symptoms are similar to those of staphylococcal food poisoning, however, the fever and severe myalgias are not associated with food poisoning. [scielo.br]

• Leg Pain

  Several hours after admission, leg pain and purpura-like skin color appeared. [ncbi.nlm.nih.gov]

  Image credits: https://drhem.wordpress.com/2012/04/ [erythroderma image] http://www.freeimages.com/photo/pain-1366480 [leg pain image] About Latest Posts Josh Farkas Josh is the creator of PulmCrit.org. [emcrit.org]

• Skin Rash

  A misconception is that TSS presents with a skin rash and only occurs in women and children; however, it can occur in males and can present without skin changes. [ncbi.nlm.nih.gov]

  […] with peeling of the skin, especially of the palms and soles, occurs during the acute phase Syndrome characterized by high fever, vomiting, diarrhea, confusion, and skin rash; almost all cases have been related to an infection with toxin-producing staphylococcus [icd9data.com]

• Flushing

  Areas that could contain the bacteria, such as surgical wounds and the vagina, are flushed out with water (irrigated). [msdmanuals.com]

  Next to the bed, there was a tube of black toxins that had been flushed out of her bloodstream. She looked out the window and saw a series of little houses outside, which her brain groggily associated with the Southwest. [vice.com]

  The amount of fluid that flowed from wide-open bottles and flushed through me in the first 24 hours 'would stagger the imagination of many physicians,' Dr. Root declared. [nytimes.com]

• Eczema

  Predisposing factors include trauma, surgery, burns and eczema, less commonly associated factors includes insect bites and subcutaneous insulin injection, an association between the use of non-steroidal anti-inflammatory and NF has been reported [ 9 ] [casesjournal.biomedcentral.com]

• Tampon Use

  Doctors say all of that was caused by TSS, a bacterial infection caused by heavy tampon use in younger women. According to experts, bacteria can grow during a woman's menstrual cycle, particularly with tampon use. [aol.com]

  Subsequently it was found to be associated with tampon use in menstruating women and Group A streptococcal infections - the streptococcal toxic shock-like syndrome (STSS). [patient.info]

• Oliguria

  Over the course of the next 24 to 48 h, generalized edema of face, hands and feet, arthralgias, particularly of the wrists, knees, ankles, fingers, and toes, the erythroderma, conjunctival injection, cough, dizziness and syncope, incontinence, and oliguria [scielo.br]

• Confusion

  TSS resulting from infection with the bacterium Staphylococcus aureus typically manifests in otherwise healthy individuals via signs and symptoms including high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress [en.wikipedia.org]

  […] vomiting, diarrhea, and myalgia, followed by hypotension and in severe cases, shock; a sunburn-like rash with peeling of the skin, especially of the palms and soles, occurs during the acute phase Syndrome characterized by high fever, vomiting, diarrhea, confusion [icd9data.com]

  Other symptoms can include confusion or other mental changes, decreased urination, fatigue and weakness, and thirst. [kidshealth.org]

  If you experience symptoms [which include sudden high fever, low blood pressure, vomiting, diarrhea, rash, confusion, muscle aches, redness of the eyes, mouth and throat, seizures and headaches], remove the product right away and contact your health care [people.com]

  They include: A sunburn-like rash, and/or peeling skin A high fever Severe flu-like symptoms Headache or muscle aches Stomach cramps Sore throat Nausea or vomiting Diarrhea Weakness Dizziness, lightheadedness, or confusion Pale, clammy skin How to Reduce [pamf.org]

• Headache

  […] tool=bestpractice.com Although the presenting signs and symptoms can be non-specific (e.g., fever, chills, myalgias, headache), the course of the disease is precipitous, and shock and multi-organ system failure occur early in the course of the disease [bestpractice.bmj.com]

  She complained of fever for one day with headache and abdominal pain after the fever developed. [ncbi.nlm.nih.gov]

  Flu-like symptoms, such as headaches, chills and a sore throat can be linked to TSS. [bbc.co.uk]

  Other symptoms can include a fever of over 102 degrees, nausea, vomiting, headaches, and muscle aches. If these symptoms occur, it's important to seek medical attention as soon as possible. [medicaldaily.com]

• Dizziness

  If you experience sudden fever, vomiting, diarrhea, dizziness or muscle aches, immediately discontinue tampon use and consult with your doctor. [michigan.gov]

  Warning signs of TSS include: sudden high fever (usually 102ºF or more) accompanied by vomiting and/or diarrhea, fainting or near-fainting when standing up and dizziness or a sunburn-like rash. [web.archive.org]

  These toxins cause a massive drop in blood pressure (shock), resulting in dizziness and confusion. They also damage tissue, including skin and organs, and can disturb many vital organ functions. [hse.ie]

  They include: A sunburn-like rash, and/or peeling skin A high fever Severe flu-like symptoms Headache or muscle aches Stomach cramps Sore throat Nausea or vomiting Diarrhea Weakness Dizziness, lightheadedness, or confusion Pale, clammy skin How to Reduce [pamf.org]

  This means that you will need to do this at least 3 times in 24 hours Wash your hands before and after handling your Mooncup Symptoms of Toxic Shock Syndrome TSS symptoms often mimic flu and can include: sudden high fever vomiting diarrhoea dizziness [mooncup.co.uk]

• Altered Mental Status

  We report the case of a 45-year-old Japanese woman who on receiving chemotherapy for advanced breast cancer developed an altered mental status and dysarthria soon after fever from infection of a subcutaneous implantable port. [ncbi.nlm.nih.gov]

  The physical findings for staph TSS are fever, tachycardia, hypotension, sun burn type rash (90%), and altered mental status. [clinicaladvisor.com]

• Lethargy

  […] the areas of the body Liver impairment Shedding of the skin in large sheets, especially over the palms and soles (this does not always occur) Difficulty breathing The following are the most common symptoms of C. sordellii TSS: Nausea and/or vomiting Lethargy [hopkinsmedicine.org]

  The central nervous system examination is impressive for the confusion, agitation, or lethargy without focal findings. [scielo.br]

No single test would be helpful in diagnosing TSS. A series and combination of methods needs to be employed for appropriately diagnosing the condition. The following methods are carried out for diagnosis:

• Blood tests to determine complete blood count which would reveal leukocytosis in individuals who have developed TSS. In addition, blood cultures are carried out to determine the presence of bacteria.
• Urine analysis is done to evaluate presence of myoglobinuria and hemoglobinuria.
• Imaging studies such as CT scan and chest X-ray are also indicated to determine the functioning of various organs [8].

• Pyuria

  Laboratory findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting [icd9data.com]

  […] phosphokinase level at least twice the upper limit of normal Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia Renal: blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria [wwwn.cdc.gov]

  Severe myalgia or creatine phosphokinase level at least twice the upper limit of normal Mucous membrane : Vaginal, oropharyngeal, or conjunctival hyperemia Renal : BUN or creatinine at least twice the upper limit of normal or urinary sediment with pyuria [lifeinthefastlane.com]

• Hypoalbuminemia

  Laboratory findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting [icd9data.com]

  Because fluid loss into tissues can occur throughout the body (because of systemic capillary leak syndrome and hypoalbuminemia), shock may be profound and resistant. [merckmanuals.com]

  Leukocytosis - 48% Abnormal urinary sediment - 46% Elevated creatine kinase levels - 41% Immature leukocytes - 36% Abnormal laboratory findings in patients with streptococcal TSS include the following: Elevated serum creatinine levels Hemoglobinuria Hypoalbuminemia [emedicine.com]

  Intravenous albumin is generally required if hypotension persists, largely because of the capillary leak syndrome and profound hypoalbuminemia that ensues. [clinicaladvisor.com]

• Liver Enzymes Abnormal

  An elevated white blood cell count, elevated liver enzymes, abnormal electrolytes, and abnormal kidney function may be consistent with toxic shock syndrome. Women undergo a pelvic exam. [emedicinehealth.com]

• Hypophosphatemia

  Most dramatic are the rapid rises in serum creatinine and blood urea nitrogen levels and the yet to be elucidated hypocalcemia and hypophosphatemia. [glowm.com]

• Hypophosphatemia

  Most dramatic are the rapid rises in serum creatinine and blood urea nitrogen levels and the yet to be elucidated hypocalcemia and hypophosphatemia. [glowm.com]

• Staphylococcus Aureus

  An exotoxin-mediated illness caused by bacterial infection, most commonly group A streptococcus or Staphylococcus aureus. [bestpractice.bmj.com]

  […] due to methicillin susceptible Staphylococcus aureus Toxic shock syndrome due to MRSA Toxic shock syndrome due to MSSA Toxic shock syndrome due to other Staph Toxic shock syndrome due to Staphylococcus Clinical Information A rare acute life-threatening [icd9data.com]

  aureus/genetics* Staphylococcus aureus/growth & development Staphylococcus aureus/pathogenicity Superantigens/biosynthesis* Superantigens/genetics Vagina/microbiology* Substances Bacterial Toxins Enterotoxins RNA, Ribosomal, 16S Superantigens enterotoxin [ncbi.nlm.nih.gov]

• Leukocytosis

  Laboratory findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting [icd9data.com]

  FBC often shows leukocytosis and low platelets. U&Es may show raised urea and creatinine, electrolyte disturbance and hypocalcaemia. CK and LFTs may be elevated. Urinalysis may show microscopic haematuria/myoglobinuria. [patient.info]

  The following methods are carried out for diagnosis: Blood tests to determine complete blood count which would reveal leukocytosis in individuals who have developed TSS. [symptoma.com]

The primary and major goal of treatment of TSS is to restore the vital functioning of the organs of the body. Individuals may need to be hospitalized until the vital signs are under control. This would be achieved by administration of antibiotics through the intravenous route to ward off the infections. Of lately, FDA approved 3 antibiotics to be used for treatment of TSS. These include tedizolid, dalbavancin and oritavancin. These drugs are known to be active against species of Staphylococcus aureus and Streptococcus [8]. Other medications would also be employed to stabilize the patient and bring the blood pressure back to normal levels. Intravenous fluids are also administered to correct dehydration. If complications have already set in such as kidney failure then dialysis is indicated in such cases.

If the syndrome is caused due to foreign agents such as tampons or vaginal sponge, then preliminary the foreign matter would be removed. If wound from injury are cause of infection, then surgical debridement of the infected tissue is indicated. Individuals are also given gamma globulin injections which help in boosting the immunity status of the affected individuals [9] [10].

The onset of the symptoms of TSS is pretty quick and turns fatal in about 50% of cases. Early recognition of the signs of the syndrome is very important to prevent the onset of complications. Individuals who survive the condition can suffer from recurrent attacks of the syndrome.

In many instances, TSS can severely affect the functioning of various organs such as kidney, liver and heart. The development of shock due to toxin production by the bacteria can severely impair the physical and mental functioning of the affected individuals [6].

TSS can affect individuals of any age group. It is primarily caused due to toxins produced by the Staphylococcus aureus. Individuals with infections of the skin, burns, open wounds and surgery are more susceptible to contract toxic shock syndrome. The toxin producing variety of Staphylococcus aureus often target the population who are at risk of developing the syndrome [2].

TSS is a rare condition and its incidence underwent significant decline after 1980. However, rise in number of cases of TSS was reported in the year 2000. It has been estimated that the syndrome occurs in about 3 to 4 out of every 100,000 users of tampons per year [3].

For the bacterial toxins to produce effect and cause development of characteristic symptoms, the causative organism must gain entry inside the body. Once infection occurs, the bacteria produce toxins which are systemically absorbed by the human body. Manifestations of signs and symptoms of TSS occur in those individuals who do not have antitoxin antibody protective layer. Such sequence of events causes production of cytokines which in turn induce tissue injury and shock [4] [5].

Use of high absorbent tampons has a significant association with TSS. Women are therefore advised to take a careful note of this fact and discontinue the use of such tampons. Low absorbent tampons should be preferred as these should be changed every 4 to 8 hours. Prolonged usage of such absorbent tampons can increase the risk of developing TSS. Individuals who have suffered wounds or injury are advised to regularly check their wounds for signs of infection. Regular cleaning of the wound is also expected [11].

Toxic shock syndrome (TSS) can affect menstruating women as well as men and children. The condition was first described in the year 1978 in children. Research studies have pointed towards an association between use of tampons and development of TSS in menstruating women. However, the incidence of TSS has decreased in this population owing to withdrawal of highly absorbent tampons from the market.

Definition

Toxic shock syndrome (TSS) is a life threatening condition caused by bacterial infections. In the past, TSS was associated with use of highly absorbent tampons by menstruating women. However, individuals who have suffered injuries are also susceptible to develop such a kind of syndrome.

Cause

In majority of the cases, TSS is caused due to toxins produced by the bacteria Staphylococcus aureus. In many instances, a streptococcus bacteria is also responsible for causing TSS.

Symptoms

Symptoms of TSS develop suddenly and the disease progresses at a fast pace. The signs include high fever, headaches, hypotension, vomiting and diarrhea, muscle aches, confusion, seizures and rash on palm and soles.

Diagnosis

Blood and urine tests are required for diagnosis of TSS. Blood cultures will provide information regarding the type of bacteria present. In addition, imaging tests would be necessary to evaluate the function of the vital organs of the body.

Treatment

Individuals with TSS will need to be hospitalized to be closely monitored for the vital signs. In addition, antibiotics are administered for warding off the infection from the body. Foreign bodies such as tampons are the cause of infection then these are removed. If wounds are the cause then surgical debridement of the tissues would be necessary.

1. Davies HD, McGeer A, Schwartz B. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med. Aug 22 1996;335(8):547-54.
2. Todd J, Fishaut M, Kapral F, Welch T. Toxic-shock syndrome associated with phage-group-I Staphylococci. Lancet 1978; 2:1116.
3. Shands KN, Schmid GP, Dan BB. Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl J Med. Dec 18 1980;303(25):1436-42. 
4. Davis JP, Chesney PJ, Wand PJ, LaVenture M. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med 1980; 303:1429.
5. Parsonnet J. Mediators in the pathogenesis of toxic shock syndrome: overview. Rev Infect Dis 1989; 11 Suppl 1:S263.
6. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America.Clin Infect Dis. Jul 15 2014;59(2):147-59.
7. Gourley GR, Chesney PJ, Davis JP, Odell GB. Acute cholestasis in patients with toxic- shock syndrome. Gastroenterology 1981; 81:928
8. Matsuda Y, Kato H, Ono E, Kikuchi K, Muraoka M, Takagi K, et al. Diagnosis of toxic shock syndrome by two different systems; clinical criteria and monitoring of TSST-1-reactive T cells. Microbiol Immunol. Nov 2008;52(11):513-21.
9. Rodríguez A, Rello J, Neira J, Maskin B, Ceraso D, Vasta L. Effects of high-dose of intravenous immunoglobulin and antibiotics on survival for severe sepsis undergoing surgery. Shock. Apr 2005;23(4):298-304.
10. Barry W, Hudgins L, Donta ST, Pesanti EL. Intravenous immunoglobulin therapy for toxic shock syndrome. JAMA 1992; 267:3315.
11. Keller MA, Stiehm ER. Passive immunity in prevention and treatment of infectious diseases. Clin Microbiol Rev 2000; 13:602.