Toxic Shock Syndrome

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Chapter 59 Toxic Shock Syndrome

INTRODUCTION

Description: Toxic shock syndrome (TSS) is caused by toxins produced by an often asymptomatic infection with Staphylococcus aureus. Although most commonly associated with prolonged tampon use, about 10% of TSS cases are associated with other conditions.
Prevalence: Seen in 1 to 2 per 100,000 women 15 to 44 years of age (last active surveillance done in 1987).
Predominant Age: 30 to 60 years.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: S. aureus exotoxins (TSS toxin-1, enterotoxins A, B, and C). For toxic shock to develop, three conditions must be met: there must be colonization by the bacteria, it must produce toxin, and there must be a portal of entry for the toxin. The presence of foreign bodies, such as a tampon, is thought to reduce magnesium levels, which promotes the formation of toxin by the bacteria.
Risk Factors: Infection by S. aureus, use of super-absorbency tampons, prolonged use of regular tampons, use of barrier contraceptive devices, nasal surgery, and postoperative staphylococcal wound infections.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Most common—rapid onset of fever greater than 38.9°C (102°F), hypotension, diffuse rash (the rash caused by TSS is commonly absent in places where clothing presses tightly against the skin). Hypotension may progress to severe and intractable hypotension and multisystem dysfunction.
• Other typical findings—agitation; arthralgias; confusion; diarrhea; erythema of pharynx, vulva, or vagina; conjunctiva; headache; myalgias; nausea; vomiting
• Desquamation, particularly on the palms and soles, can occur 1 to 2 weeks after onset of the illness

DIAGNOSTIC APPROACH

Differential Diagnosis

• Other exanthems (acute rheumatic fever, bullous impetigo, drug reaction, erythema multiforme, Kawasaki disease, leptospirosis, meningococcemia, Rocky Mountain spotted fever, rubella, rubeola, scarlet fever, viral disease)
• Gastrointestinal illness (appendicitis, dysentery, gastroenteritis, pancreatitis, staphylococcal food poisoning)
• Acute pyelonephritis
• Hemolytic uremic syndrome
• Legionnaires’ disease
• Pelvic inflammatory disease (PID)
• Reye’s syndrome
• Rhabdomyolysis
• Septic shock
• Stevens-Johnson syndrome
• Systemic lupus erythematosus
• Tick typhus

Associated Conditions: Other sources—surgical wounds (including dilation and curettage), nonsurgical focal infections, cellulitis, subcutaneous abscesses, mastitis, infected insect bites, postpartum (including transmission to the neonate), nonmenstrual vaginal conditions, vaginal infection, pelvic inflammatory disease, steroid cream use. Even the use of laminaria to dilate the cervix has been reported to be associated with rare cases.

Workup and Evaluation

Laboratory: Cultures for S. aureus, complete blood count, liver and renal function studies.
Imaging: No imaging indicated.
Special Tests: None indicated.
Diagnostic Procedures: History and physical findings.

Pathologic Findings

Lymphocyte depletion, subepidermic cleavage planes, cervical or vaginal ulcers.

Characteristics That Define Toxic Shock Syndrome

• Fever >38.9°C (102°F)
• Diffuse, macular, erythematous rash
• Desquamation of palms and soles 1 to 2 weeks after onset
• Hypotension (<90 torr systolic or orthostatic change)
• Negative blood, pharyngeal, and cerebrospinal fluid culture
• Negative serologic tests for measles, leptospirosis, Rocky Mountain spotted fever
• Three or more of the following organ systems:

Cardiopulmonary (respiratory distress, pulmonary edema, heart block, myocarditis)
Central nervous (disorientation or altered sensorium)
Gastrointestinal (vomiting, diarrhea)
Hematologic (thrombocytopenia of ≤100,000/mm3)
Hepatic (> 2-fold elevation of total bilirubin or liver enzymes, serum albumin >2 g/dL)

• Mucous membrane inflammation (vaginal, oropharyngeal, conjunctival)
• Musculoskeletal (myalgia, >2-fold elevation of creatine phosphokinase)
• Renal (pyuria, >2-fold elevation of blood urea nitrogen or creatinine)

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Rapid evaluation and supportive intervention. Aggressive support and treatment of the attendant shock is paramount. (Frank shock is common by the time the patient is first seen for care.)
Specific Measures: The site of infection must be identified and drained, most commonly by removing the contaminated tampon. Antibiotic therapy with a βlactamase-resistant antistaphylococcal agent should be started but does not alter the initial course of the illness. Other support (e.g., mechanical ventilation, pressor agents) as needed.

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Diet: As tolerated and dictated by the patient’s clinical status during acute phase.
Activity: Bed rest during initial diagnosis and therapy.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP049 (Menstruation [Especially for Teens]), AP041 (Growing Up [Especially for Teens]).

Drug(s) of Choice

Oxacillin or nafcillin 100 mg/kg/day given in divided doses every 6 hours.
Contraindications: Known or suspected allergy.
Precautions: The dose of oxacillin must be reduced if renal failure is present.
Interactions: See individual agents.

Alternative Drugs

Clindamycin 25 mg/kg/day given in divided doses every 8 hours. Vancomycin 30 mg/kg/day given in divided doses every 6 hours.

FOLLOW-UP

Patient Monitoring: Intense monitoring is required during the initial phase of treatment. After resolution, normal health maintenance.
Prevention/Avoidance: Frequent changes of tampons. Use of sanitary pads at night. Although the risk of recurrence is low (10% to 15%), patients who have had TSS should refrain from the use of tampons in the future.
Possible Complications: Adult respiratory distress syndrome is a common sequela of TSS and patients must be monitored for the development of this complication. Acute renal failure, alopecia, and nail loss also may occur.
Expected Outcome: Although the prognosis for patients with TSS is generally good, mortality rates of 5% to 10% are common.

MISCELLANEOUS

Pregnancy Considerations: Uncommon during pregnancy. May occur postpartum as a complication of operative delivery, endometritis, episiotomy infection, or nursing.
ICD-9-CM Codes: 040.89.

REFERENCES

Level II

Broome CV. Epidemiology of toxic shock syndrome in the United States. Rev Infect Dis. 1989;11:S14.

Chesney PJ, Davis JP, Purdy WK, et al. Clinical manifestations of toxic shock syndrome. JAMA. 1981;246:741.

Davis JP, Vergernot JM, Amsterdam LE, et al. Long-term effects of toxic shock syndrome in women: sequelae, subsequent pregnancy, menstrual history, and long-term trends in catamenial product use. Rev Infect Dis. 1989;11:S50.

Gavanta S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shock syndrome in the United States. 1986. Rev Infect Dis. 1989;2:S28.

Hajjeh RA, Reingold A, Weil A, et al. Toxic shock syndrome in the United States: surveillance update, 1979–1996. Emerg Infect Dis J. 1999;5:6.

Kain KC, Schulzer M, Chow AW. Clinical spectrum of nonmenstrual toxic shock syndrome (TSS): comparison with menstrual TSS by multivariate discriminant analyses. Clin Infect Dis. 1993;16:100.

Martin SR, Foley MR. Intensive care in obstetrics: an evidence-based review. Am J Obstet Gynecol. 2006;195:673.

Reingold AL, Shards KN, Dan BB, Broome CV. Toxic-shock not associated with menstruation. A review of 54 cases. Lancet. 1982;1:1.

Sutkin G, Capelle SD, Schlievert PM, Creinin MD. Toxic shock syndrome after laminaria insertion. Obstet Gynecol. 2001;98:959.

Level III

Centers for Disease Control and Prevention. Toxic-shock syndrome—United States. MMWR. 1990;39:421.

Centers for Disease Control and Prevention. Toxic-shock syndrome—United States. 1980. MMWR. 1997;46:492.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:596.

Reingold AL. Toxic shock syndrome: an update. Am J Obstet Gynecol. 1991;165:1236.

Schuchat A, Broome CV. Toxic shock syndrome and tampons. Epidemiologic Reviews. 1991;13:99.

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