Infectious Disease: Toxic Shock Syndrome

Question 1

Defintion

Answer 1

Severe systemic reaction to staphylococcal exotoxins, the TSST-1 superantigen toxin

Question 2

Aetiology

Answer 2

• Group A streptococcus (Streptococcus Pyogenes)
• Methicillin-sensitive Staphylococcus Aureus (MSSA)
• Methicillin-Resistant Staphylococcus Aureus (MRSA)

Question 3

Risk factors

Answer 3

• Extended tampon use: increases the risk of staphylococcal exotoxin production
• Postpartum infections
• Surgical procedures : breast reconstruction, hysterectomy, liposuction, bunionectomy, septorhinoplasty
• Other infections:
  = surgical wound infections, necrotising fasciitis, pneumonia
• Burns
• Retained foreign body

Question 4

Signs and symptoms

Answer 4

• Fever >38.8 degrees
• Hypotensive: Systolic < 90mmHg
• Major feature = DIFFUSE ERYTHEMATOUS RASH of the palms and soles which subsequently progress to dequamation 7-14 days later
• Disease progression can be rapid to multiple body systems:
  = gastrointestinal (diarrhoea and vomiting),
  = mucous membrane erythema,
  = renal failure,
  = hepatitis,
  = thrombocytopenia,
  = CNS involvement (e.g. confusion)

Question 5

Diagnosis

Answer 5

Blood test:
- FBC + CRP = CRP + WCC elevated, platelets may be <100 x 10 9 /L
- U+E = urea + creatinine raised due to AKI
- Coagulation screen: prothrombin time and partial thromboplastin time may be increased 2’ to DIC
MC + S = confirm diagnosis

Question 6

Treatment

Answer 6

FIRST LINE = Source control
- remove tampon or dressing
- drain infected source
IV Fluid replacement
- large volume of crystalloids may be required
- to help treat shock and hypotension
Empirical IV Abx
- CLINDAMYCIN + VANCOMYCIN

SECOND LINE:
- Culture-sensitive Abx:
= Group A Strrepococcus: penicillin
= MSSA: CLINDAMYCIN + FLUCLOXACILLIN/NAFCILLIN
= MRSA: VANCOMYCIN
- Surgical debridement = may be necessary for deep tissue infection
- ICU = required due to severe hypotension which may require vasopressors +/or treatment of multi organ failure
- IV immunoglobulin

Question 7

Complications

Answer 7

Renal failure
Liver failure
DIC and Coagulopathy
Glomerulonephritis
Rheumatic fever