Toxic Shock Syndrome

From Anvita Health Wiki

Contents 1 Etiology 2 Epidemiology 3 Pathology 4 Clinical-manifestations 5 Management 6 More General Terms 7 Additional Terms 8 References

Etiology

• epidemic of cases in menstruating women in early 1980s due to use of 'super-abdorbent' tampons
• post operative patients, esp ENT cases with nasal packs
• abscesses, gauze-packed wounds

Epidemiology

• young adults (age 15-34) most commonly affected
• women comprise 85% of cases

Pathology

• Staphylococcus aureus strains that produce:

• toxic shock exotoxin TSST-1 (20% of S aureus strains), or
• enterotoxins B or C

• Streptococcal form of toxic shock syndrome (group A)

• pyrogenic exotoxin A
• certain M types

Clinical-manifestations

• fever > 38.9 C (102.2 F)
• hypotension, < 90 mm Hg systolic
• skin manifestations

• localized or diffuse erythema 'sunburn rash' followed by peripheral desquamation in 5-14 days
• affected skin has a rough 'sandpaper' texture
• mucous membrane & conjunctival hyperemia

• diarrhea Diagnostic Criteria: ( CDC)
• fever (T > 102 F)
• hypotension

• systolic BP < 90 mm Hg
• orthostatic fall in diastolic BP > 14 mm Hg
• symptoms of orthostatic hypotension

• rash - diffuse macular erythroderma
• desquamation

• occurs 1-2 weeks after onset of symptoms
• especially on palms & soles

• involvement of 3 or more of the following organ systems

• GI: nausea, vomiting, diarrhea
• muscular: severe myalgias or serum creatine kinase ( CK) > 2-fold upper limit of normal
• mucous membranes: hyperemia, often best seen in conjunctiva
• renal: creatinine or BUN > 2-fold upper limit of normal or urinalysis with > 5 WBC/ hpf
• hepatic: transaminases or bilirubin > 2-fold upper limit of normal
• hematologic: platelets < 100,000/ mm3
• CNS: altered mental status while afebrile (non-focal exam)
• pulmonary: ARDS with Streptococcal toxic shock syndrome

• negative results on the following tests (if performed)

• blood, throat & CSF cultures ( blood culture may be positive for Staphylococcus aureus)
• negative serology for Rocky Mountain spotted fever, Leptospirosis or rubeola
• isolation of group-A beta-hemolytic Streptococci suggests Streptococcal toxic shock syndrome

Management

• fluid resuscitation

• may need massive volumes
• 10-20 L IV fluids

• albumin replacement
• vasopressor support to maintain blood pressure

• dopamine drip
• norepinephrine drip

• identify & remove source of infection & toxin

• tampon, nasal packing, abscess

• contact isolation until completion of 24 hours of antibiotic therapy
• anti-Staphylococcus antibiotics do not alter the course of the disease, but do reduce recurrence rate

• nafcillin & clindamycin
• vancomycin or linezolid for MRSA

• no role for corticosteroids or immune globulin [1]

• Prognosis:

• overall mortality 2-5% (higher in non- menstrual cases)
• recurrence rate of 30% - recurrent episodes less severe

More General Terms

• bacterial infection
• skin disease (dermatologic disorder, dermatopathy, dermatosis)

Additional Terms

• erythema
• Staphylococcus aureus

References

1. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, American College of Physicians, Philadelphia 2006, 2009
2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 93

toxic shock syndrome