Toxic shock syndrome

Question 1

Toxic shock syndrome (TSS) is a multisystem inflammatory response to the presence of bacterial exotoxins, specifically staphylococcus aureus and streptococci pyogenes. What is the incidence of Staphylococcal toxic shock syndrome (STSS)?

1 - 2 cases per 100,000
2 - 20 cases per 100,000
3 - 200 cases per 100,000
4 - 2000 cases per 100,000

Answer 1

1 - 2 cases per 100,000

Staphylococcus aureus us a gram-positive bacterium

Typically caused by a retained foreign body or tampon or soft tissue/skin injury

Question 2

Is Staphylococcal toxic shock syndrome (STSS) more common in men or women?

Answer 2

• women

Mainly because STSS is commonly associated with tampon use

Question 3

At what age does the incidence of Staphylococcal toxic shock syndrome (STSS) typically occur?

1 - >65
2 - 30-50
3 - 6-15
4 - 1-5

Answer 3

3 - 6-15

Question 4

The most common cause of toxic shock syndrome is Staphylococcus aureus. Is it endotoxins or exotoxins that can trigger STSS?

Answer 4

• exotoxins

Able to cross-link MHC-II molecules on APCs with T-cell receptors, leading to polyclonal T-cell activation, triggering an excessive immune response

Endotoxins = internal toxins
Exotoxins= externally released toxins

Question 5

Following the release of the super-antigen exotoxins from Staphylococcus aureus induces an excessive immune response and pro-inflammatory state. Which of the following can this then cause?

1 - hypotension due to vasodilation
2 - capillary leak syndrome
3 - multiorgan failure
4 - systemic inflammatory response syndrome (SIRS)
5 - all of the above

Answer 5

5 - all of the above

Multiorgan failure occurs due to vasodilation and secondary hypoperfusion of organs

Question 6

Which of the following are risk factors for developing toxic shock syndrome (TSS)?

1 - immunocompromised
2 - nasal colonisation carriers of S. aureus
3 - menses and tampon use
4 - surgical procedures
5 - cuts and burns
6 - all of the above

Answer 6

6 - all of the above

Question 7

Which of the following is NOT part of the typical clinical triad presentation of toxic shock syndrome (TSS)?

1 - sudden onset of high fever (>38.9)
2 - hypertension
3 - diffuse, macular erythroderma
4 - hypotension

Answer 7

2 - hypertension

Patients may also have nausea, vomiting and diarrhoea

Mucosal hyperaemia in conjunctival, oral, and vaginal mucousa may also occur (excessive blood vessels)

Macular erythroderma = serious red and flat widespread skin redness, peeling, and scaling of the skin.

The rash is typically blanching

Question 8

In addition to the macular erythroderma, there can also be desquamation of the skin that can occur after 1-2 weeks. Where does this typically occur?

1 - face and neck
2 - palms of hands and soles of feet
3 - genital and axillary region
4 - abdomen

Answer 8

2 - palms of hands and soles of feet

Question 9

Macular erythroderma is a condition referred to as skin failure. What % of the skin is said to be affected to be diagnosed with Erythroderma?

1 - >50%
2 - >70%
3 - >80%
4 - >90%

Answer 9

4 - >90%

This would be in severe cases.

Question 10

Hypotension can occur and car result in shock in toxic shock syndrome (TSS), where the systolic BP can drop as low as?

1 - <150 mmHg
2 - <120 mmHg
3 - <90 mmHg
4 - <50 mmHg

Answer 10

3 - <90 mmHg

Question 11

Patients with toxic shock syndrome may also experience myalgias and arthralgias. What marker can often be raised and give the suspicion rhabdomyolysis?

1 - urea
2 - reduced eGFR
3 - creatine kinase
4 - troponin

Answer 11

3 - creatine kinase

Question 12

If we suspect a diagnosis of toxic shock syndrome (TSS), all of the following are key to help diagnose and guide management of the patient, but which is least important?

1 - Blood cultures
2 - Serum creatinine and urea levels
3 - Liver function tests (LFTs)
4 - Thyroid function tests
5 - C-reactive protein (CRP) and FBC
6 - Blood gas analysis

Answer 12

4 - Thyroid function tests

• Blood cultures = may be negative in TSS
• Serum creatinine + urea = AKI
• Liver function = multiorgan involvement
• C-reactive protein (CRP) and full blood count
• Elevated CRP = inflammation
• Elevated leukocyte (neutrophils more common due to bacterial cause)
• Blood gas analysis = respiratory status and metabolic disturbances. Metabolic acidosis may suggest severe sepsis or septic shock.

Question 13

If we suspect a diagnosis of toxic shock syndrome, should we wait for test results before we give antibiotics?

Answer 13

• no

Provide broad spectrum antibiotics, but can change them later

Question 13

Do we typically rely on diagnosing toxic shock syndrome on tests or clinical diagnosis?

Answer 13

• clinical diagnosis

Triad of fever, hypotension and macular erythroderma

Question 14

Which of the following should be implemented in patients with suspected toxic shock syndrome (TSS)?

1 - oxygen
2 - fluid resuscitation
3 - broad spectrum antibiotics
4 - blood cultures
5 - ABG
6 - urine output and central venous pressure
7 - all of the above

Answer 14

7 - all of the above

Essentially the same as the sepsis 6

Vasopressors (vasoconstriction) may be needed if hypotension persists despite fluid bolus

IV immunoglobulins may be used in severe or refractory TSS

Question 15

What is typically the 1at line antibiotics given in toxic shock syndrome?

1 - gentamicin and amoxycillin
2 - amoxycillin and clindamyacin
3 - flucloxacillin and clindamycin
4 - gentamicin and clindamycin

Answer 15

3 - flucloxacillin and clindamycin

But this is guided by trust specific guidelines