Toxic Shock Syndrome Flashcards
Define toxic shock syndrome and its types
Exotoxin-mediated illness caused by bacterial infection
Menstrual TSS: women during menstruation with extended use of a single tampon or highly absorbable tampons
Non-menstrual TSS: staphylococcal post-partum vaginal and caesarean wound infections
Aetiology of toxic shock syndrome
Group A streptococcus (strep. Pyogenes): skin, vagina, pharynx
MRSA: associated with tampon use and postpartum infections
Staph aureus: associated with tampon use and postpartum infections
Exotoxin release → inflammatory cytokine release → shock and multi-organ failure
Risk factors for toxic shock syndrome
Diabetes mellitus
Alcoholism
Minor trauma and injuries with bruising, haematoma formation, muscle strain
Surgical procedures e.g. vaginal delivery, C-section, breast reconstruction, hysterectomy, liposuction, bunionectomy
Single tampon used continuously for consecutive days during menses
Using highly absorbent tampons
NSAID use, contraceptive sponge use, diaphragm use, IUDs, untreated strep throat
Symptoms of toxic shock syndrome
Severe diffuse or localised pain in an extremity
Fever
Localised swelling or erythema
Diffuse erythematous rash (often becomes erythrodermic, covering >90% of the body surface, including mucosal membranes)
Hypothermia
Flu-like symptoms: chills, myalgias, nausea, vomiting, diarrhoea
Cerebral hypoperfusion + oedema: confusion, agitation, reduced consciousness
Myositis: Muscular tenderness and weakness
Peritonitis: severe abdominal pain and tenderness, staying still
Myocarditis: chest pain, dyspnoea, orthopnoea, syncope, fatigue, and palpitations
Endophthalmitis
Streptococcal toxic shock syndrome: fever, pain, soft-tissue swelling, and/or vesicle and bullae formation
Signs of toxic shock syndrome on examination
Obs
- Hypotension
- Fever
- Hypothermia (most common early sign)
General
- Severe diffuse or localised pain in an extremity
- Localised swelling or erythema
- Diffuse, scarlatina-like erythematous rash
Neuro/MSK
- Muscular tenderness and weakness
Abdominal exam
- Diffuse abdominal pain
- Rebound tenderness
Guarding
Investigations of toxic shock syndrome
Wound swab for MC&S
Urinalysis: ?renal failure
Blood culture
FBC: raised WCC, anaemia, thrombocytopenia
Coagulation: prolonged PT/PTT
U&Es: ?renal failure
LFTs: raises ALT/AST, bilirubin
CK: elevated
Calcium: hypocalcaemia in strep
Serum albumin: low
VBG: raised lactate
CXR: ?ARDS
Management for toxic shock syndrome
Suspected - arrange transfer to intensive care unit
Fluid resuscitation (Massive fluid resuscitation is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension)
Empirical antibiotic therapy: clindamycin 900mG IV AND imipenem 500mg IV
- Confirmed strep: clindamycin + benzylpenicillin
- Confirmed MRSA: clinda + vancomycin
Vasopressor support for hypotension
Source control e.g. remove tampon, drain existing abscesses
Surgical debridement
+ ICU support → stress ulcer prophylaxis (H2 antagonists or PPIs), DVT prophylaxis (heparin, LMWH, compression stockings), enteral nutirition
Complications of toxic shock syndrome
Cerebral hypoperfusion + oedema
Myositis
Peritonitis
Myocarditis
Endophthalmitis
Invasive streptococcal infection: bacteraemia | meningitis | pneumonia | empyema | peritonitis | septic arthritis | puerperal sepsis | burn wound sepsis | necrotising fasciitis | gangrenous myositis
ARDS
DIC
Renal failure
Waterhouse-Friderichsen syndrome (acute haemorrhagic adrenal insufficiency)
Neuropsychiatric sequalae: headache, memory loss, poor concentration
Prognosis for toxic shock syndrome
Streptococcal TSS: Mortality ranges from 30-85% DESPITE antibiotic therapy
Increased mortality: shock, advanced age, hypotension, multi-organ system failure
Non-menstrual staphylococcal TSS: mortality rate 5%
Death is usually due to refractory cardiac arrhythmias, cardiomyopathy, and respiratory failure
