Toxic Shock Syndrome (TSS) - Infectious Diseases - MSD ...

Toxic Shock Syndrome (TSS) - Etiology, pathophysiology, symptoms, signs, diagnosis & prognosis from the MSD Manuals - Medical Professional Version. MSDManual Pleaseconfirmthatyouareahealthcareprofessional Yes No LeavethisSite? Thelinkyouhaveselectedwilltakeyoutoathird-partywebsite.Wedonotcontrolorhaveresponsibilityforthecontentofanythird-partysite. 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Streptobacillaryrat-bitefeveriscausedbyStreptobacillusmoniliformis,anorganismfoundintheoropharynxofhealthyrats.Ifapatientisbittenbyaninfectedrat,symptomscanbegintodevelopwithinaperiodof1to22days.Whichofthefollowingsymptomsofthisdiseasetendstodevelopabout3daysaftertheinitialsymptoms?  Headache  Jointpain  Rash  Septicarthritis   MoreContent Videos 3DModels News SOCIALMEDIA ToxicShockSyndrome(TSS) By LarryM.Bush ,MD,FACP,CharlesE.SchmidtCollegeofMedicine,FloridaAtlanticUniversity; MariaT.Vazquez-Pertejo ,MD,FACP,WellingtonRegionalMedicalCenter Lastfullreview/revisionMar2021|ContentlastmodifiedMar2021 ClickhereforPatientEducation TopicResources 3DModels(0) Audios(0) Calculators(0) Images(1) LabTest(0) Tables(0) Videos(0) StaphylococcalToxicShockSyndrome Toxicshocksyndromeiscausedbystaphylococcalorstreptococcalexotoxins.Manifestationsincludehighfever,hypotension,diffuseerythematousrash,andmultipleorgandysfunction,whichmayrapidlyprogresstosevereandintractableshock.Diagnosisismadeclinicallyandbyisolatingtheorganism.Treatmentincludesantibiotics,intensivesupport,andIVimmuneglobulin.Toxicshocksyndrome(TSS)iscausedbyexotoxin-producingcocci.Strainsofphage-group1StaphylococcusaureuselaboratetheTSStoxin-1(TSST-1)orrelatedexotoxins;certainstrainsofStreptococcuspyogenesproduceatleast2exotoxins.StaphylococcaltoxicshockAthighestriskofstaphylococcalTSSareWomenwhohavepreexistingstaphylococcalcolonizationofthevaginaandwholeavetamponsorotherdevices(eg,contraceptivesponges,diaphragms)inthevaginaMechanicalorchemicalfactorsrelatedtotamponuseprobablyenhanceproductionoftheexotoxinorfacilitateitsentryintothebloodstreamthroughamucosalbreakorviatheuterus.Estimatessuggestabout3cases/100,000menstruatingwomenstilloccur,andcasesarestillreportedinwomenwhodonotusetamponsandinwomenwhohaveinfectionafterchildbirth,abortion,orsurgery.About15%ofcasesoccurpostpartumorasacomplicationofpostoperativestaphylococcalwoundinfectionsthatappearinsignificant.CaseshavealsobeenreportedinbothmenandwomenwithanytypeofS.aureusinfection.MortalityfromstaphylococcalTSSis<3%.Recurrencesarecommonamongwomenwhocontinuetousetamponsduringthefirst4monthsafteranepisode.StreptococcaltoxicshockStreptococcalTSSissimilartothatcausedbyS.aureus,butmortalityishigher(20to60%)despiteaggressivetherapy.Inaddition,about50%ofpatientshaveS.pyogenesbacteremia,and50%havenecrotizingfasciitisNecrotizingSoftTissueInfectionNecrotizingsofttissueinfectionistypicallycausedbyamixtureofaerobicandanaerobicorganismsthatcausenecrosisofsubcutaneoustissue,usuallyincludingthefascia.Thisinfection...readmore(neitheriscommonwithstaphylococcalTSS).Patientsareusuallyotherwisehealthychildrenoradults.Primaryinfectionsinskinandsofttissuearemorecommonthaninothersites.IncontrasttostaphylococcalTSS,streptococcalTSSismorelikelytocauseacuterespiratorydistresssyndromeAcuteHypoxemicRespiratoryFailure(AHRF,ARDS)Acutehypoxemicrespiratoryfailureisseverearterialhypoxemiathatisrefractorytosupplementaloxygen.Itiscausedbyintrapulmonaryshuntingofbloodresultingfromairspacefillingor...readmore(ARDS)andlesslikelytocauseatypicalcutaneousreaction.S.pyogenesTSSisdefinedasanygroupAbeta-hemolyticstreptococci(GABHS)infectionassociatedwithshockandorganfailure.RiskfactorsforGABHSTSSincludeMinortraumaSurgicalproceduresViralinfections(eg,varicella)Useofnonsteroidalanti-inflammatorydrugs(NSAIDs)SymptomsandSignsofToxicShockSyndromeOnsetoftoxicshocksyndromeissudden,withFever(39to40.5°C,whichremainselevated)Hypotension(whichcanberefractory)AdiffusemacularerythrodermaInvolvementofatleast2otherorgansystemsStaphylococcalTSSislikelytocausevomiting,diarrhea,myalgia,elevatedcreatinekinase,mucositis,hepaticdamage,thrombocytopenia,andconfusion.ThestaphylococcalTSSrashismorelikelytodesquamate,particularlyonthepalmsandsoles,between3and7daysafteronset.StreptococcalTSScommonlycausesacuterespiratorydistresssyndrome(inabout55%ofpatients),coagulopathy,andhepaticdamageandismorelikelytocausefever,malaise,andseverepainatthesiteofasoft-tissueinfection.Renalimpairmentisfrequentandcommontoboth.Thesyndromemayprogresswithin48hourstosyncope,shock,anddeath.LessseverecasesofstaphylococcalTSSarefairlycommon.DiagnosisofToxicShockSyndromeClinicalevaluationCulturesDiagnosisoftoxicshocksyndrome(TSS)ismadeclinicallyandbyisolatingtheorganismfrombloodcultures(forStreptococcus)orfromthelocalsite.TSSresemblesKawasakidiseaseKawasakiDiseaseKawasakidiseaseisavasculitis,sometimesinvolvingthecoronaryarteries,thattendstooccurininfantsandchildrenbetweentheagesof1yearand8years.Itischaracterizedbyprolonged...readmore,butKawasakidiseaseusuallyoccursinchildren<5yearsofageanddoesnotcauseshock,azotemia,orthrombocytopenia;therashismaculopapular.OtherdisorderstobeconsideredarescarletfeverScarletfeverStreptococciaregram-positiveaerobicorganismsthatcausemanydisorders,includingpharyngitis,pneumonia,woundandskininfections,sepsis,andendocarditis.Symptomsvarywiththeorgan...readmore,ReyesyndromeReyeSyndromeReyesyndromeisarareformofacuteencephalopathyandfattyinfiltrationoftheliverthattendstooccuraftersomeacuteviralinfections,particularlywhensalicylatesareused.Diagnosis...readmore,staphylococcalscaldedskinsyndromeStaphylococcalScaldedSkinSyndromeStaphylococcalscaldedskinsyndromeisanacuteepidermolysiscausedbyastaphylococcaltoxin.Infantsandchildrenaremostsusceptible.Symptomsarewidespreadbullaewithepidermalsloughing...readmore,meningococcemiaMeningococcalDiseasesMeningococci(Neisseriameningitidis)aregram-negativecoccithatcausemeningitisandmeningococcemia.Symptoms,usuallysevere,includeheadache,nausea,vomiting,photophobia,lethargy,...readmore,RockyMountainspottedfeverRockyMountainSpottedFever(RMSF)RockyMountainspottedfever(RMSF)iscausedbyRickettsiarickettsiiandtransmittedbyixodidticks.Symptomsarehighfever,severeheadache,andrash.(SeealsoOverviewofRickettsial...readmore,leptospirosisLeptospirosisLeptospirosisisaninfectioncausedbyoneofseveralpathogenicserotypesofthespirocheteLeptospira.Symptomsarebiphasic.Bothphasesinvolveacutefebrileepisodes;the2ndphasesometimes...readmore,andviralexanthematousdiseasesExanthematousinfectionsCategorizingviralinfectionsbytheorgansystemmostcommonlyaffected(eg,lungs,gastrointestinaltract,skin,liver,centralnervoussystem,mucousmembranes)canbeclinicallyuseful,...readmore.Thesedisordersareruledoutbyspecificclinicaldifferences,cultures,andserologictests.Specimensforcultureshouldbetakenfromanylesions,thenose(forstaphylococci),throat(forstreptococci),vagina(forboth),andblood.MRIorCTofsofttissueishelpfulinlocalizingsitesofinfection.Continuousmonitoringofrenal,hepatic,bonemarrow,andcardiopulmonaryfunctionisnecessary.TreatmentofToxicShockSyndromeLocalmeasures(eg,decontamination,debridement)FluidresuscitationandcirculatorysupportEmpiricantibiotictherapy(eg,clindamycinplusvancomycinordaptomycin)pendingcultureresultsPatientssuspectedofhavingTSSshouldbehospitalizedimmediatelyandtreatedintensively.Tampons,diaphragms,andotherforeignbodiesshouldberemovedatonce.Suspectedprimarysitesshouldbedecontaminatedthoroughly.DecontaminationincludesReinspectionandirrigationofsurgicalwounds,eveniftheyappearhealthyRepeateddebridementofdevitalizedtissuesIrrigationofpotentialnaturallycolonizedsites(sinuses,vagina)Fluidsandelectrolytesarereplacedtopreventortreathypovolemia,hypotension,andshock.Becausefluidlossintotissuescanoccurthroughoutthebody(becauseofsystemiccapillaryleaksyndromeandhypoalbuminemia),shockmaybeprofoundandresistant.Aggressivefluidresuscitationandcirculatory,ventilatory,and/orhemodialysissupportaresometimesrequired.Obviousinfectionsshouldbetreatedwithantibiotics(forindicationsanddoses,).Pendingcultureresults,clindamycinorlinezolid(tosuppresstoxinproduction)plusvancomycin,daptomycin,linezolid,orceftaroline—empiricchoicesthatcoverthemostlikelyetiologicorganisms—shouldbeused.Ifapathogenisisolatedonculture,theantibioticregimenisadjustedasneeded,asforthefollowing:ForgroupAstreptococci:Clindamycinplusabeta-lactamFormethicillin-susceptibleS.aureus(MSSA):ClindamycinplusoxacillinornafcillinFormethicillin-resistantStaphylococcusaureus(MRSA):Vancomycinordaptomycinplusclindamycinorlinezolid,dependingonthesusceptibilityAntibioticsgivenduringtheacuteillnessmayeradicatepathogenfociandpreventrecurrences.PassiveimmunizationtoTSStoxinswithIVimmuneglobulin(2g/kg,followedby0.4g/kgdailyforupto5days)hasbeenhelpfulinseverecasesofbothtypesofTSSandlastsforweeks,butthediseasemaynotinduceactiveimmunity,sorecurrencesarepossible.IfatestforseroconversionoftheserumantibodyresponsestoTSST-1inacute-andconvalescent-phasepairedseraisnegative,womenwhohavehadstaphylococcalTSSshouldprobablyrefrainfromusingtamponsandcervicalcaps,plugs,anddiaphragms.Advisingallwomen,regardlessofTSST-1antibodystatus,tochangetamponsfrequentlyorusenapkinsinsteadandtoavoidhyperabsorbenttamponsseemsprudent.KeyPointsToxicshocksyndrome(TSS)iscausedbyexotoxin-producingstrainsofStaphylococcusaureusandStreptococcuspyogenes.Althoughclassicallydescribedasoccurringwithtamponuse,TSSmayoccuraftermanystaphylococcalorstreptococcalsoft-tissueinfections.Onsetofsymptomsissudden;symptomsincludehighfever,hypotension(whichcanberefractory),diffuseerythematousrash,andmultipleorgandysfunction.Provideaggressivesupportivecare,anddecontaminateand/ordebridethesourcesite.Giveantibiotics(eg,clindamycinplusvancomycinordaptomycin)pendingcultureandsusceptibilitytesting.GiveIVimmuneglobulinifTSSissevere. ClickhereforPatientEducation NOTE: ThisistheProfessionalVersion. CONSUMERS: ClickherefortheConsumerVersion ©2021MerckSharp&DohmeCorp.,asubsidiaryofMerck&Co.,Inc.,Kenilworth,NJ,USA StreptococcalInfections WasThisPageHelpful? Yes No Anthrax OTHERTOPICSINTHISCHAPTER Gram-PositiveCocci EnterococcalInfections PneumococcalInfections StaphylococcalInfections StreptococcalInfections ToxicShockSyndrome(TSS) Professionalsalsoread OverviewofNephriticSyndrome OverviewofNephroticSyndrome OverviewofHereditaryPeriodicFeverSyndromes Testyourknowledge Rat-BiteFever Streptobacillaryrat-bitefeveriscausedbyStreptobacillusmoniliformis,anorganismfoundintheoropharynxofhealthyrats.Ifapatientisbittenbyaninfectedrat,symptomscanbegintodevelopwithinaperiodof1to22days.Whichofthefollowingsymptomsofthisdiseasetendstodevelopabout3daysaftertheinitialsymptoms?  Headache  Jointpain  Rash  Septicarthritis       MSDandtheMSDManuals Merck&Co.,Inc.,Kenilworth,NJ,USA (knownasMSDoutsideoftheUSandCanada)isaglobalhealthcareleaderworkingtohelptheworldbewell.Fromdevelopingnewtherapiesthattreatandpreventdiseasetohelpingpeopleinneed,wearecommittedtoimprovinghealthandwell-beingaroundtheworld. TheManualwasfirstpublishedin1899asaservicetothecommunity.ThelegacyofthisgreatresourcecontinuesastheMSDManualoutsideoftheUnitedStatesandCanada. LearnmoreaboutourcommitmenttoGlobalMedicalKnowledge. 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