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Toxic Shock Syndrome

TSS

Toxic shock syndrome, abbreviated as TSS, is a life threatening condition caused due to bacterial infections. It often occurs due to toxins produced by the Staphylococcus aureus [1].


Presentation

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
  • She complained of fever for one day with headache and abdominal pain after the fever developed.[ncbi.nlm.nih.gov]
  • 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]
  • CSTE Position Statement(s) 10-ID-14 Clinical Criteria An illness with the following clinical manifestations: Fever: temperature greater than or equal to 102.0 F (greater than or equal to 38.9 C) Rash: diffuse macular erythroderma Desquamation: 1-2 weeks[wwwn.cdc.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]
  • These mild symptoms may include low-grade fever, muscle aches, chills, and malaise (a feeling of general discomfort, uneasiness, or ill health).[emedicinehealth.com]
  • CDC criteria for Staphylococcus TSS include: Fever of 102 degrees F or higher Chills Malaise (uneasiness and despair) Headache Fatigue Red, flat rash that covers most of the areas of the body Shedding of the skin in large sheets, especially over the palms[stanfordchildrens.org]
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]
  • A 77-year-old man with diabetes and a gastric ulcer was urgently admitted due to prolonged nausea and vomiting. Computed tomography revealed widespread diffuse thickening of the gastric wall, and PG was suspected.[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]
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]
  • 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]
  • 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.[symptoma.com]
Nausea
  • A 77-year-old man with diabetes and a gastric ulcer was urgently admitted due to prolonged nausea and vomiting. Computed tomography revealed widespread diffuse thickening of the gastric wall, and PG was suspected.[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
  • Toxic Shock Syndrome Pictures Toxic shock syndrome commonly causes a red strawberry tongue. Click to view larger image.[emedicinehealth.com]
  • This can be associated with hyperemia of the pharynx and conjunctiva, possibly with a “strawberry tongue” appearance (below).[emcrit.org]
  • Strawberry tongue. Reproduced with permission from Drage, LE. Life-threatening rashes: dermatologic signs of four infectious diseases. Mayo Clin Proc. 1999;74:68-72.[emedicine.com]
Hypotension
  • Toxic shock syndrome (TSS) is an acute toxin-mediated infectious syndrome characterized by fever, hypotension, desquamation, and multiorgan involvement.[ncbi.nlm.nih.gov]
  • 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]
  • […] s) 10-ID-14 Clinical Criteria An illness with the following clinical manifestations: Fever: temperature greater than or equal to 102.0 F (greater than or equal to 38.9 C) Rash: diffuse macular erythroderma Desquamation: 1-2 weeks after onset of rash Hypotension[wwwn.cdc.gov]
Tachycardia
  • 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]
  • The physical findings for staph TSS are fever, tachycardia, hypotension, sun burn type rash (90%), and altered mental status.[clinicaladvisor.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]
  • 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]
Refractory Shock
  • Despite conventional treatment, the patient developed refractory shock, which was immediately improved with PMX-DHP.[ncbi.nlm.nih.gov]
Red Eye
  • Recognising the signs TSS can cause a number of symptoms, these include: diarrhoea a sudden high temperature (40 C or above) confusion dizziness tiredness vomiting aching muscles headaches low blood pressure red eyes, mouth and throat a red rash found[healthdirect.gov.au]
  • They may include Red skin rash that looks like sunburn Red eyes (conjunctivitis) Watery diarrhea Vomiting Severe muscle aches Confusion Low blood pressure A week or more after the beginning of the skin rash, the skin around the nails may begin to peel[healthychildren.org]
  • Symptoms The symptoms of TSS start very suddenly: High fever: 102 degrees Fahrenheit (38.8 degrees Celsius) or higher Fainting Rapid drop in blood pressure Confusion Diarrhea Fatigue Headache Low urine output Overall muscle pain Red eyes Seizures Sunburn-like[sepsis.org]
  • Symptoms can include: confusion extreme fatigue and weakness high fever of 39 C to 40.5 C (102 F to 105 F) headache red eyes severe diarrhea sore throat vomiting widespread red rash In severe cases, the symptoms get rapidly worse over the next 24 to 48[medbroadcast.com]
Flushing
  • Areas that could contain the bacteria, such as surgical wounds and the vagina, are flushed out with water (irrigated).[merckmanuals.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]
Exanthema
  • Differential Diagnosis of Toxic Shock Syndrome Exanthemas Kawasaki's disease (mucocutaneous lymph node syndrome)* Streptococcal scarlet fever* Staphylococcal scarlet fever* Rubeola and rubella Meningococcemia and other septicemias* Rocky Mountain spotted[glowm.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]
Myalgia
  • […] 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]
  • An influenzalike syndrome, consisting of fever, chills, myalgia, nausea, vomiting, and diarrhea, may be noted in 20% of patients.[emedicine.com]
  • Myalgia and muscle weakness are common. Confusion and disorientation may indicate encephalopathy. Examination should seek evidence of the source of the infection by: Close examination of the skin. Checking for tampons; gynaecological examination.[patient.info]
Tampon Use
  • Signs and symptoms Tampon use can increase the risk of TSS.[medicalnewstoday.com]
  • 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]
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
  • […] 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]
  • 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]
  • Have someone else drive, especially if the person is feeling lightheaded or confused. Women who are menstruating and using a tampon should remove the tampon prior to going to the hospital.[emedicinehealth.com]
Headache
  • She complained of fever for one day with headache and abdominal pain after the fever developed.[ncbi.nlm.nih.gov]
  • 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.[symptoma.com]
  • 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]
  • 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]
  • 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]
  • 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]

Workup

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]
Staphylococcus Aureus
  • Convert to ICD-10-CM : 040.82 converts directly to: 2015/16 ICD-10-CM A48.3 Toxic shock syndrome Approximate Synonyms Staphylococcal toxic shock syndrome Toxic shock syndrome due to methicillin resistant Staphylococcus aureus infection Toxic shock syndrome[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]
  • 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.[symptoma.com]

Treatment

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].

Prognosis

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].

Etiology

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].

Epidemiology

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].

Sex distribution
Age distribution

Pathophysiology

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].

Prevention

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].

Summary

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.

Patient Information

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.

References

Article

  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.

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Last updated: 2019-07-11 21:12