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Toxic Shock Syndrome: Follow-up

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

Follow-up

Transfer

Most patients who develop TSS are critically ill and should be transferred to an intensive care unit of an institution capable of caring for these patients.

Deterrence/Prevention

  • Patients who recover from TSS are at risk of recurrent episodes of STSS. Consider or recommend preventive therapy (eg, discontinuation of tampon usage, administration of antistaphylococcal antibiotics) before and during each menstrual period for several months.
  • Chemoprophylaxis of household contacts of STSS patients: Household contacts of people with STSS have a higher risk of invasive GAS infection compared to the general population. The Centers for Disease Control and Prevention have not made definite recommendations; some authors have recommended a 10-day course of cephalosporin.

Complications

  • Severe complications from STTS include the following:6
    • Prolonged and refractory hypovolemic shock (95%)
    • Adult respiratory distress syndrome (55%)
    • Acute renal failure (reversible in 70%, irreversible 10%)
    • Bacteremia (60%)
    • Electrolyte and acid-base imbalance
    • Cardiac dysrhythmia
    • Disseminated intravascular coagulation with thrombocytopenia
  • STSS carries a mortality rate of 3%, and streptococcal TSS has a mortality rate of 30%.
  • TSS may recur in patients who are not treated with beta-lactamase–resistant antimicrobial drugs.
  • Some patients with streptococcal TSS have respiratory symptoms and develop lobar consolidation and empyema. This condition may need to be distinguished from overwhelming Streptococcus pneumoniae sepsis.

Patient Education

  • Patient education about early signs and symptoms, risk factors and avoidance of tampon use may help prevent relapses.
  • For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Toxic Shock Syndrome.

Miscellaneous

Medicolegal Pitfalls

  • Streptococcal TSS emerged as a serious infectious disease in the 20th century.
  • Streptococcal TSS is associated with GAS infection and shock and multiorgan failure.
  • Rapid progression of what appears to be cellulitis, swelling, formation of vesicles, and bullae is an ominous sign.
  • Emergent surgical exploration should be performed to distinguish GAS infection from other causes and debride the necrotic tissues.
  • In a female who develops a shock state, a history and/or examination for tampon use should be performed. The STSS should be considered in the differential diagnosis.
  • Streptococcal TSS should be considered in any patient who presents from the community in shock. Empirical therapy should be undertaken because culture results may not be available for 24 hours.
  • Acute meningococcemia may be confused with streptococcal shock syndrome because of the petechial rash.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors Godfrey Harding, MD, FRCP(C), and Ken Dolynchuk, MD, PhD, FRCSC, to the development and writing of this article.



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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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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