Toxic Shock Syndrome

TSS results from toxin-producing Staphylococcus aureus or Streptococcus pyogenes. Superantigen activity causes broad T-cell activation and cytokine release, producing capillary leak, hypotension, and multiorgan dysfunction. CDC+1CDCSuperantigens and Streptococcal Toxic Shock Syndrome - Volume 9, Number 10—October 2003 - Emerging Infectious Diseases journal - CDCPubMedToxic Shock Syndrome - StatPearls - NCBI Bookshelf STSS is defined by GAS infection with abrupt shock and organ failure; hypotension generally develops within 24 to 48 hours after initial symptoms. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC

A diffuse rash is helpful but not required for early action. In a pediatric series, 48% of STSS cases lacked rash; delayed use of clindamycin and IVIG was associated with longer hospitalization among children without rash. CDCCDCManifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010–2017 - Volume 26, Number 6—June 2020 - Emerging Infectious Diseases journal - CDC TSS may arise from a small or occult focus, and blood cultures can be negative in staphylococcal disease. ScienceDirectScienceDirectLesson of the month 2: Toxic shock syndrome

STSS should be especially considered with severe focal pain out of proportion to examination, recent surgery or skin disruption, varicella-associated skin lesions, diabetes, alcohol use disorder, or age 65 years or older. NSAID exposure may increase risk, although evidence is limited. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC

There is no single diagnostic test for TSS. Obtain blood cultures and cultures from any suspected source before antimicrobials when this does not delay treatment. Evaluate organ involvement with CBC and platelets, comprehensive metabolic panel, creatine kinase, coagulation studies, urinalysis, and assessment for pulmonary involvement. CDC+1CDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDCPubMedToxic Shock Syndrome - StatPearls - NCBI Bookshelf

For STSS surveillance classification, the CSTE case definition requires hypotension, multiorgan involvement, and GAS isolation; isolation from a sterile site supports a confirmed case. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC These criteria optimize specificity and should not be treated as bedside prerequisites for empiric therapy. CDCCDCManifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010–2017 - Volume 26, Number 6—June 2020 - Emerging Infectious Diseases journal - CDC

Early imaging should be directed by the suspected source and must not postpone exploration when necrotizing soft-tissue infection is plausible. In STSS, severe pain can precede prominent local findings, and bullae or violaceous progression should prompt emergent surgical exploration. CDCCDCStreptococcal Toxic-Shock Syndrome

Hospitalize patients with suspected STSS. Begin standard shock management with intravenous fluid resuscitation and organ support; add vasopressors when hypotension persists despite fluids. CDC+1CDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDCPubMedToxic Shock Syndrome - StatPearls - NCBI Bookshelf Serially reassess hemodynamics, urine output, respiratory failure, renal function, hepatic injury, coagulation abnormalities, and evolving skin or soft-tissue findings. CDC+1CDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDCPubMedToxic Shock Syndrome - StatPearls - NCBI Bookshelf

Source control is time-critical. Remove tampons, packing, or other retained foreign material; drain abscesses; and obtain urgent surgical assessment for suspected deep infection. CDC specifically notes that surgical debridement may be necessary in STSS. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC

For confirmed or strongly suspected STSS, CDC identifies penicillin plus clindamycin as first-line antibiotics. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC Clindamycin is used in combination, not alone, because it suppresses toxin production but is bacteriostatic. PubMedPubMedToxic Shock Syndrome - StatPearls - NCBI Bookshelf The supplied sources do not provide a U.S. dosing regimen for penicillin or clindamycin; use current institutional severe invasive GAS pathways and adjust to kidney function, allergy history, and microbiology results.

STSS can progress from influenza-like symptoms to hypotension within 24 to 48 hours. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC Organ failure may involve renal, hepatic, respiratory, hematologic, and soft-tissue systems; complications include need for debridement or amputation. CDC+1CDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDCCDCAbout Streptococcal Toxic Shock Syndrome | Group A Strep | CDC

CDC reports that STSS mortality can exceed 30% despite aggressive treatment and is higher with advancing age. CDCCDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDC In historical clinical descriptions, deep soft-tissue infection commonly required debridement, fasciotomy, or amputation. CDCCDCStreptococcal Toxic-Shock Syndrome

Monitor serial hemodynamics, vasopressor requirement, urine output and creatinine, platelets and coagulation studies, hepatic tests, oxygenation, CK when myositis is suspected, and repeated examination of the implicated soft-tissue compartment. CDC+2CDCClinical Guidance for Streptococcal Toxic Shock Syndrome | Group A Strep | CDCCDCStreptococcal Toxic-Shock SyndromePubMedToxic Shock Syndrome - StatPearls - NCBI Bookshelf