toxic shock syndrome

Question 1

what is toxic shock syndrome?

Answer 1

severe illness characterised by multisystemic inflammation triggered by bacterial exotoxins.

Question 2

what are the most common causes?

Answer 2

Staphylococcus aureus and Group A Streptococcus are the bacteria responsible, and infection can occur post-surgery, from another infection such as cellulitis or from tampons or moon cups (although this is now less common than other causes).

Question 3

describe the aetiology

Answer 3

• caused by bacterial production of exotoxins
• exotoxins act as superantigens, causing excessive activation of the immune system
• involves T cell activation and a cytokine storm with interleukins and TNF-alpha
• presents with a multisystem inflammatory state which can lead to shock, multiorgan failure and death

Question 4

what is key to note about staph and strep respectively?

Answer 4

• staphylococcal TSS is caused by either methicillin-sensitive (MSSA) or resistant (MRSA) Staphylococcus aureus
• streptococcal TSS is caused by Group A Streptococcus (Streptococcus pyogenes) and is a notifiable disease

Question 5

what are the features?

Answer 5

• Fevers
• Rash - generalised erythema, resembles sunburn
• Desquamation, especially palms and soles of feet
• Erythema of the mucous membranes and tongue
• Hypotension
• n+v
• Diarrhoea
• Myalgia and muscle weakness
• Confusion and disorientation
• Dizziness
• Headache

Question 6

what are differentials?

Answer 6

• cellulitis
• meningococcal septicaemia
• Steven-johsnon
• viral infection with exanthem
• gram -ve sepsis

Question 7

what are the bedside tests?

Answer 7

swabs - microscopy, culture + sensitivities
blood gas - High lactate, acid-base abnormalities, deranged glucose
urinalysis - myoglobuinuria, microscopic haematuria

Question 8

what bloods do you do?

Answer 8

blood culture
FBC - high WCC, thrombocytopenia
U+Es - AKI, electrolyte disturbance
LFTs - acute liver injury + deranged
CRP - high
CK - elevated
coat = deranged, DIC
group + save

Question 9

what imaging do you do?

Answer 9

CXR in pts with features of ARDS, which may complicate strep TSS

Question 10

what is the mx?

Answer 10

IV abx eg linezolid/clindamycin (suppress toxins) + penicillin/cephalosproin/vancomycin (broad spec)

remove any focus of infection
IV fluids
catheterise
correct electrolyte imbalance + coagulopathy
consider admission

Question 11

what are the complications?

Answer 11

ARDS
haemolytic anaemia
renal failure
DIC
VTE
peptic ulcer
rhabdomyolysis
cardiomyopathy
encephalopathy
recurrence