Criteria for Staphylococcal Toxic Shock Syndrome (TSS)
- Temperature >38.9degC
- Systolic blood pressure <90 mmHg
- Diffuse macular erythroderma
- Subsequent desquamation, especially on the palms and soles
- Involvement of 3+ of the following organ systems:
- Gastrointestinal: vomiting, profuse diarrhea
- Muscular: severe myalgias or >5-fold increase in CPK
- Mucous membranes (vagina, conjunctivae, or pharynx): frank hyperemia
- Renal insufficiency: urea or creatinine >2x upper limit of normal with pyuria in the absence of UTI
- Liver (hepatitis): bilirubin, AST, ALT >2x upper limit of normal
- Blood: thrombocytopenia <100,000/mm3
- Central nervous system: disorientation without focal neurologic signs
- Negative results of serologic tests for Rocky Mountain spotted fever, leptospirosis, and measles
6 of these is a confirmed case. But toxic shock criteria are there for research rather than clinical work – just treat if at all suspicious! For staph related TSS, blood culture usually (but not always) negative, although may be isolated from wound or trachea.
For streptococcal toxic shock syndrome, almost always associated with a healthy looking recent wound, or recent varicella. Criteria are looser but microbiological confirmation required:
- Isolation of GAS from a sterile site (1A) or non-sterile site (1B)
- Hypotension plus multisystem involvement (2+):
- generalized erythroderma, +/- desquamation [only 1 point!}
- soft tissue necrosis
1A plus 2 is a confirmed strep TSS case, 1B plus 2 is probable.
TSST-1 found in 75% of cases, the rest feature enterotoxins B or C. Recurrence is very rare. 90% of the adult population have antibodies against TSST1, not surprising since 20% of staphs are TSST-1 positive!!! Test is genotype based, not toxin based, so other factors must affect whether toxins are released, or how much disease is caused.
Females outnumber males 3:1.
Clindamycin has added benefit due to ability to reduce toxin production. IVIG has theoretical benefit but the only trial was stopped because of slow recruitment. Haemofiltration similarly has theoretical benefit.