The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature

Abstract

Background

Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately.

Objective

This review provides an emergency medicine evidence-based summary of the current evaluation and treatment of TSS.

Discussion

The most common etiologic agents are Staphylococcus aureus and Streptococcus pyogenes. Sources of TSS include postsurgical wounds, postpartum, postabortion, burns, soft tissue injuries, pharyngitis, and focal infections. Symptoms are due to toxin production and infection focus. Early symptoms include fever, chills, malaise, rash, vomiting, diarrhea, and hypotension. Diffuse erythema and desquamation may occur later in the disease course. Laboratory assessment may demonstrate anemia, thrombocytopenia, elevated liver enzymes, and abnormal coagulation studies. Diagnostic criteria are available to facilitate the diagnosis, but they should not be relied on for definitive diagnosis. Rather, specific situations should trigger consideration of this disease process. Treatment involves intravenous fluids, source control, and antibiotics. Antibiotics should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid.

Conclusion

TSS is a potentially deadly disease requiring prompt recognition and treatment. Focused history, physical examination, and laboratory testing are important for the diagnosis and management of this disease. Understanding the evaluation and treatment of TSS can assist providers with effectively managing these patients.

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.