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Toxic Shock Syndrome: Keys in Diagnosis and Management

There are several differences between streptococcal and staphylococcal TSS, though they can present similarly. Staphylococcal TSS symptoms more commonly result from the toxin, rather than the site of infection and include fever, diarrhea, vomiting, influenza-like symptoms (headache, soreness, and sore throat), confusion, or lethargy. Unfortunately, patients with staphylococcal TSS are often misdiagnosed with gastroenteritis, influenza, or viral illness. Streptococcal TSS more commonly presents with symptoms from the local site of invasive infection such as cellulitis, pharyngitis, pneumonia, or necrotizing fasciitis. However, up to 45% of patients do not display a localized site of infection.59…

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  Peds

Some bugs are really vicious! The weapons that Staph and Strep possess are quite impressive and aggressive! Keep Toxic Shock Syndrome on your list! You may be correct in diagnosing that cause of the shock is infection, but don’t overlook the possible circulating bacterial exotoxins! Fight the Toxins! Add Clindamycin to your protocoled antibiotic selections.

 Peds - Don't Forget the Bubbles

Adrenaline and noradrenaline have both vasopressor and inotropic effects. These are used widely and are effective in treating children with fluid-resistant shock. These vasoactive agents should be considered after 40-60ml/kg of fluid resuscitation (or sooner if there is evidence of fluid overload). There are no studies directly comparing these agents in children. Either can be used first line. Adrenaline and noradrenaline should be administered centrally. However, if central venous access is not available and it is an emergency, consensus opinion is that they may be diluted and administered peripherally (intravenous) or given undiluted via the intraosseous route until more definitive central venous access is obtained.

Articles of Interest

Toxic Shock Syndrome Management: A tale of two patients

The primary problem in TSS is often not the presence of bacteria in the tissues, but rather toxin secretion causing massive cytokine release. Therefore, antibiotic therapy focuses on protein-synthesis inhibiting drugs which act immediately to shut off toxin synthesis. Clindamycin is the most widely recommended antibiotic for toxin suppression.

Menstrual toxic shock syndrome

In the early stages of TSS, empirical antibiotic therapy is often started because TSS can be difficult to differentiate from sepsis.

Staphylococcal toxic shock syndrome: EM-focused highlights

TSS is often a late diagnosis, and there have been many unfortunate cases, which were initially given a more benign diagnosis. Systemic illness plus blanchable, diffuse rash or ‘pain out of proportion’ should clue the clinician into TSS, either from S. aureus or S. pyogenes. Half of the cases are from tampon use, while other common precipitants include nasal packing and surgical wound infections.

Toxic Shock Syndrome – Diagnosis

It is caused by some subgroups of Staph or Strep which produce exotoxins (ex. staphylococcal TSST-1) that act as a superantigen, over-activating the immune system by bypassing the usual steps of the immune sequence.

Resources

Toxic Shock Syndrome

TSS should be considered in all patients with fever, rash, hypotension, and evidence of organ dysfunction... Penicillin G 24 million units/day IV in divided doses (Streptococcal TSS) OR Nafcillin2 gm IV q4h or Oxacillin 2 gm IV q4h (Staphylococcal TSS) AND Clindamycin900 mg IV every 8 hours (suppress toxin production)