Clinical Reviews in Emergency MedicineThe Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature
Introduction
Toxic shock syndrome (TSS) is an acute, toxin-mediated illness characterized by fever, hypotension, multi-organ dysfunction, and a diffuse rash with desquamation (1). The disease can be rapidly lethal and is usually treatable, though physicians often fail to recognize this condition. The annual incidence has been suggested to range from 1.5–11 per 100,000 people 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. Cases occur most commonly at the extremes of age, with one study finding that the highest incidence occurred in adults aged > 45 years, followed by children < 5 years, and was lowest in persons aged 16–45 years (5). Another study found higher rates among children < 2 years of age and adults ≥ 65 years of age (6). TSS is more commonly seen in winter and spring, with a lower incidence in summer and autumn months 6, 7, 8, 9, 10, 11, 12.
Although TSS is most commonly associated with Staphylococcus aureus and Streptococcus pyogenes, several other infections have also been associated with this illness, including Streptococcus agalactiae, Streptococcus viridans, Group C Streptococcus, Group G Streptococcus, and Clostridium soredellii 13, 14, 15, 16, 17, 18, 19, 20, 21. Staphylococcal TSS was first described in 1978 in association with an S. aureus infection in children, followed by an epidemic in the 1980s, occurring in association with tampon use 1, 22, 23. However, changes in the manufacturing and use of tampons led to a significant decline in the incidence of menstrual-related staphylococcal TSS, whereas the incidence of nonmenstrual staphylococcal TSS has increased 1, 24, 25. Nonmenstrual staphylococcal TSS has been associated with postsurgical, postpartum, postabortion, intrauterine device placement, burns, soft tissue injuries, and focal infections (e.g., pneumonia, influenza) 1, 10, 21, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37.
Streptococcal TSS occurs more commonly after viral infections (e.g., varicella, influenza), pharyngitis, and local soft tissue trauma 1, 10, 26, 38, 39, 40, 41. Streptococcal TSS is associated with deeper sites of infection (e.g., infection after penetrating injuries, necrotizing fasciitis) and has higher rates of morbidity and mortality than staphylococcal TSS (1). Overall TSS mortality for adults ranges from 30–80% for TSS, whereas mortality in children is much lower and ranges from 3–10% 1, 9, 10, 25, 42.
Section snippets
Methods
Authors searched PubMed and Google Scholar for articles using the keyword “toxic shock syndrome.” The literature search was restricted to studies published in English. Authors decided which studies to include for the review by consensus. A total of 112 articles were selected for inclusion in this review.
Pathogenesis
TSS is caused by a host response to superantigens from the associated bacteria (commonly S. aureus or S. pyogenes) 1, 43, 44, 45, 46, 47, 48, 49. Superantigens are a group of proteins that can directly activate T cells by bypassing certain steps of the antigen-mediated immune response sequence 1, 43, 44, 46, 47, 49. This causes a massive, uncontrolled T-cell activation, resulting in the release of a substantial amount of cytokines 1, 43, 44, 46, 47, 48, 49. This leads to recruitment and further
Conclusions
Toxic shock syndrome (TSS) is a potentially lethal, toxin-mediated illness that can mimic several other diseases. Staphylococcus aureus and Streptococcus pyogenes are the most common etiologic agents. Sources of TSS include burns, soft tissue injuries, postsurgical wounds, postpartum, postabortion, pharyngitis, and focal infections. Symptoms can include fever, chills, rash, vomiting, diarrhea, and hypotension. Laboratory values may demonstrate anemia, thrombocytopenia, elevated liver enzymes,
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This review does not reflect the views or opinions of the U.S. government, Department of Defense, U.S. Army, U.S. Air Force, or the San Antonio Uniformed Services Health Education Consortium Emergency Medicine Residency Program.