Pathophysiology
1) multisystem organ dysfunction secondary to release of toxins by Staphylococcus aureus or Streptococcus pyogenes 2) associated with use of hyperabsorbent tampons (usually Staph etiology)
Signs and Symptoms
1) abrupt onset of fever 2) vomiting 3) diarrhea 4) myalgias 5) abdominal pain 6) headache 7) sore throat 8) “strawberry tongue” 9) neurological deficits 10) erythematous mucous membranes (conjunctiva, oropharynx, vagina) 11) rapid progression to hypotension with renal and cardiac failure 12) scarlatina skin rash starting 5-7 days after onset (also sometimes intense rubor described as erythroderma occurs) 13) desquamation occurring 7-10 days ofter onset on palms and soles (Staph etiology only) 14) late sequelae – peripheral gangrene, asthenia, neuropsychiatric deficits.
Characteristic Test Findings
Laboratory – 1) thrombocytopenia 2) DIC with decreased fibrinogen and increased fibrin split products 3) increased creatinine and BUN 4) pus in urine (pyuria) 5) increased bilirubin 6) increased transaminases 7) decreased albumin 8) hypocalcemia 9) hypophosphatemia 10) increased CPK 11) “left shift” on WBC count 12) bacteremia (Strep etiology only)
Histology/Gross Pathology
1) microthrombi in viscera 2) erythroderma is more common in Staph than in Strep etiology
Associated Conditions
increased incidence in – 1) immunosuppression 2) osteomyelitis 3) barrier contraceptive use 4) childbirth 5) burns 6) insect bites 7) varicella infection 8) influenza infection 9) acute sinusitis 10) surgical wounds 11) ARDS
Biochemistry
implicated Staph toxins are toxic shock toxin 1 (TSS-1) and enterotoxin B
Inheritance/Epidemiology
1) 50% of cases associated with tampon use 2) mortality is 5% in tampon-related TSS, 10% in non-tampon-related TSS, and 50% in Strep toxic shock syndrome (almost never tampon-related)
Treatment
1) clindamycin (best) or nafcillin for 14 days 2) IV immunoglobulin in severe cases 3) aggressive fluid resuscitation 4) re-exploration and debridement of surgical wounds or involved site (even if innocuous looking)
Tips for USMLE
1) if a 23 year old women developed an acute onset of fever to 104.5 F, multiple episodes of vomiting, abdominal pain, hypotension, and then 3 days later developed a “sunburn” type of rash on her chest, think toxic shock syndrome 2) if question mentions tampons, think toxic shock syndrome.
