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Toxic Shock Syndrome: Differential Diagnoses & Workup

Author: Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Contributor Information and Disclosures

Updated: May 1, 2009

Differential Diagnoses

Cellulitis
Pharyngitis, Bacterial
Clostridial Gas Gangrene
Pneumonia, Bacterial
Erythema Multiforme (Stevens-Johnson Syndrome)
Sepsis, Bacterial
Fever of Unknown Origin
Septic Shock
Gas Gangrene
Shock, Distributive
Infectious Mononucleosis
Shock, Hemorrhagic
Infective Endocarditis
Staphylococcal Infections
Kawasaki Disease
Streptococcus Group A Infections
Listeria Monocytogenes
Meningococcal Infections
Meningococcemia

Other Problems to Be Considered

The differential diagnosis includes the following:

Heat stroke
Leptospirosis
Rubeola
Rocky Mountain spotted fever (RMSF): Severe headache and rash are present in most patients with this disorder. The rash is petechial in patients with RMSF, whereas it is diffusely erythematous in patients with TSS.
Rash-associated viral infections
Meningococcemia
Streptococcal or staphylococcal scarlet fever
Drug reactions
Kawasaki syndrome
Toxic epidermal necrolysis
Gram-negative sepsis: This condition may mimic TSS but is uncommon in healthy patients outside the hospital setting.
Typhoid fever: This is a food-borne illness that also should be distinguished from TSS.

Workup

Laboratory Studies

  • CBC count with differential
    • Leukocytosis with a polymorphonuclear shift to the left
    • Mild leukocytosis with significant immature neutrophils on peripheral smear
  • Urinalysis
    • Myoglobinuria and hemoglobinuria present
    • Sterile pyuria
  • Prolonged prothrombin and activated partial thromboplastin times
  • Serum biochemistry
    • Serum creatinine - Frequently elevated and precedes the development of hypotension in 50% of cases
    • Hypoglycemia
    • Low serum protein and albumin concentrations
    • Elevated blood urea nitrogen
    • Elevated transaminases
    • Elevated bilirubin and creatine phosphokinase levels
    • In myositis or narcotizing fascitis, elevated serum creatinine kinase concentration
  • Blood cultures
    • Blood cultures positive for bacteria - Present in approximately 60% of the cases of disease associated with GAS
    • Compared with STSS, blood cultures usually positive for staphylococci
  • Gram stain and cultures
    • S aureus - Identified easily by Gram stain and culture from a well-defined focus of infection (eg, abscess, wound infection)
    • In cases associated with menstruation, as many as 90% of patients demonstrate the organism in cultures from the cervix or vagina, in the absence of clinical infection.
    • S aureus bacteriemia - Uncommon in patients with TSS
  • Common laboratory abnormalities in patients with streptococcal TSS10 :
  • Hypoalbuminemia (85%)
  • Hypocalcemia (79%)
  • Elevated liver transaminase levels (63%)
  • Prolonged prothrombin time and/or activated partial thromboplastin time (60-71%)
  • Elevated creatinine level (40-89%)

Imaging Studies

  • Chest radiographs: Patients who develop multiorgan dysfunction will have bilateral airspace infiltrates consistent with acute respiratory distress syndrome.

Staging

Case definition of streptococcal TSS

  • Isolation of GAS
    1. From a sterile site
    2. From a nonsterile body site
  • Clinical signs of severity
    1. Hypotension
    2. Clinical and laboratory abnormalities (requires 2 or more of the following): (1) renal impairment; (2) coagulopathy; (3) liver abnormalities; (4) acute respiratory distress syndrome; (5) extensive tissue necrosis, ie, necrotizing fasciitis; and (6) erythematous rash.
  • Definite case - Isolation of GAS from a sterile site and hypotension and 2 or more of the clinical and laboratory abnormalities
  • Probable case - Isolation of GAS from a nonsterile body site and hypotension and 2 or more of the clinical and laboratory abnormalities

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
Multimedia: Toxic Shock Syndrome
References
Further Reading
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References

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Further Reading

Clinical guidelines
Female barrier methods.
Faculty of Sexual and Reproductive Healthcare - Professional Association.  2007 Jun.  17 pages.  NGC:006305

Practice guidelines for the diagnosis and management of skin and soft-tissue infections.
Infectious Diseases Society of America - Medical Specialty Society.  2005 Nov 15.  34 pages.  NGC:004581

Clinical trials

 Long Term Follow-up of Patients With Group A Streptococcal Infection Originating From the Genital Tract

Early-Onset Sepsis Surveillance Study

Related eMedicine topics

 Staphylococcus Aureus Infection

Streptococcal Infection, Group A

Staphylococcal Infections

Toxic Shock Syndrome (Dermatoloy)

Toxic Shock Syndrome (Emergency Medicine)

Toxic Shock Syndrome (Pediatrics)

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Keywords

toxic shock syndrome, TSS, flesh-eating disease, toxic shock, septic shock, Staphylococcus aureus, S aureus, group A Streptococcus, GAS, Streptococcus pyogenes, S pyogenes

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Contributor Information and Disclosures

Author

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Cory Franklin, MD, Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital
Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard B Brown, MD, FACP, Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine
Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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