eMedicine Specialties > Dermatology > Bacterial Infections

Toxic Shock Syndrome: Differential Diagnoses & Workup

Author: Steven M Manders, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania; Associate Professor, Department of Internal Medicine, Division of Dermatology, University of Medicine and Dentistry of New Jersey
Coauthor(s): Clara-Dina Cokonis, MD, Staff Physician, Department of Medicine, Division of Dermatology, Cooper Hospital University Medical Center
Contributor Information and Disclosures

Updated: Jul 15, 2008

Differential Diagnoses

Acanthosis Nigricans
Kawasaki Disease
Scarlet Fever
Staphylococcal Scalded Skin Syndrome

Other Problems to Be Considered

Drug-induced hypersensitivity syndrome
Febrile drug reaction
Leptospirosis

Workup

Laboratory Studies

  • Blood cultures - Positive in 5-15% of TSS and approximately 50% of STSS
  • CBC count - Leukocytosis and thrombocytopenia
  • Chemistry profile
    • Elevated BUN and creatinine as well as abnormal LFTs
    • Occasional hypocalcemia - Unclear basis
  • Urinalysis - Microscopic hematuria and occasional myoglobinuria
  • Creatinine kinase - Occasionally elevated secondary to muscle injury

Histologic Findings

A clinical diagnosis is often made. The histologic findings, although nonspecific in some cases, are usually quite characteristic and consist of a superficial perivascular and interstitial mixed-cell infiltrate that contains neutrophils and sometimes eosinophils. Foci of spongiosis-containing neutrophils and scattered necrotic keratinocytes sometimes are clustered within the epidermis. When present, bullae are subepidermal in location.

More on Toxic Shock Syndrome

Overview: Toxic Shock Syndrome
Differential Diagnoses & Workup: Toxic Shock Syndrome
Treatment & Medication: Toxic Shock Syndrome
Follow-up: Toxic Shock Syndrome
References
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References

  1. Shands KN, Schmid GP, Dan BB, Blum D, Guidotti RJ, Hargrett NT, et al. Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases. N Engl J Med. Dec 18 1980;303(25):1436-42. [Medline].

  2. Rosen H. Superantigens. Int J Dermatol. Jan 1997;36(1):14-6. [Medline].

  3. Haddadin DW, Samnani IQ, Moorman JP. Drotrecogin alfa (activated) for nonmenstrual toxic shock syndrome associated with methicillin resistant Staphylococcus aureus infection. South Med J. Nov 2006;99(11):1295-6. [Medline].

  4. Darenberg J, Ihendyane N, Sjölin J, Aufwerber E, Haidl S, Follin P, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis. Aug 1 2003;37(3):333-40. [Medline].

  5. Davis JP, Chesney PJ, Wand PJ, LaVenture M. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med. Dec 18 1980;303(25):1429-35. [Medline].

  6. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. Mar 2004;32(3):858-73. [Medline].

  7. Drage LA. Life-threatening rashes: dermatologic signs of four infectious diseases. Mayo Clin Proc. Jan 1999;74(1):68-72. [Medline].

  8. Durand G, Bes M, Meugnier H, Enright MC, Forey F, Liassine N, et al. Detection of new methicillin-resistant Staphylococcus aureus clones containing the toxic shock syndrome toxin 1 gene responsible for hospital- and community-acquired infections in France. J Clin Microbiol. Mar 2006;44(3):847-53. [Medline].

  9. Hoge CW, Schwartz B, Talkington DF, Breiman RF, MacNeill EM, Englender SJ. The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic shock-like syndrome. A retrospective population-based study. JAMA. Jan 20 1993;269(3):384-9. [Medline].

  10. Larkin SM, Williams DN, Osterholm MT, Tofte RW, Posalaky Z. Toxic shock syndrome: clinical, laboratory, and pathologic findings in nine fatal cases. Ann Intern Med. Jun 1982;96(6 Pt 2):858-64. [Medline].

  11. Manders SM. Toxin-mediated streptococcal and staphylococcal disease. J Am Acad Dermatol. Sep 1998;39(3):383-98; quiz 399-400. [Medline].

  12. Nelson C. Early recognition and treatment of staphylococcal and streptococcal toxic shock. J Pediatr Adolesc Gynecol. Aug 2004;17(4):289-92. [Medline].

  13. Reingold AL, Hargrett NT, Shands KN, Dan BB, Schmid GP, Strickland BY. Toxic shock syndrome surveillance in the United States, 1980 to 1981. Ann Intern Med. Jun 1982;96(6 Pt 2):875-80. [Medline].

  14. Stevens DL. The toxic shock syndromes. Infect Dis Clin North Am. Dec 1996;10(4):727-46. [Medline].

  15. Strausbaugh LJ. Toxic shock syndrome. Are you recognizing its changing presentations?. Postgrad Med. Nov 1 1993;94(6):107-8, 111-3, 117-8. [Medline].

  16. Wenisch C, Laferl H, Szell M, Smolle KH, Grisold A, Bertha G, et al. A holistic approach to MRSA eradication in critically ill patients with MRSA pneumonia. Infection. Jun 2006;34(3):148-54. [Medline].

  17. Wolf JE, Rabinowitz LG. Streptococcal toxic shock-like syndrome. Arch Dermatol. Jan 1995;131(1):73-7. [Medline].

  18. Wood TF, Potter MA, Jonasson O. Streptococcal toxic shock-like syndrome. The importance of surgical intervention. Ann Surg. Feb 1993;217(2):109-14. [Medline].

  19. Working Group on Severe Streptococcal Infections. Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections. JAMA. Jan 20 1993;269(3):390-1. [Medline].

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Further Reading

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Keywords

shock, TSS, STSS, toxic strep, streptococcal toxic shock-like syndrome, streptococcal TSS, Staphylococcus aureus, S aureus

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Contributor Information and Disclosures

Author

Steven M Manders, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania; Associate Professor, Department of Internal Medicine, Division of Dermatology, University of Medicine and Dentistry of New Jersey
Steven M Manders, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Clara-Dina Cokonis, MD, Staff Physician, Department of Medicine, Division of Dermatology, Cooper Hospital University Medical Center
Clara-Dina Cokonis, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Franklin Flowers, MD, Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, University of Florida College of Medicine
Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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