eMedicine Specialties > Emergency Medicine > Infectious Diseases

Toxic Shock Syndrome: Differential Diagnoses & Workup

Author: Vicken Y Totten, MD, MS, FACEP, FAAFP, Assistant Professor, Case Western Reserve University School of Medicine; Director of Research, Department of Emergency Medicine, University Hospitals, Case Medical Center
Coauthor(s): Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Contributor Information and Disclosures

Updated: Aug 31, 2009

Differential Diagnoses

Dermatitis, Exfoliative
Shock, Septic
Heat Exhaustion and Heatstroke
Staphylococcal Scalded Skin Syndrome
Leptospirosis in Humans
Stevens-Johnson Syndrome
Malaria
Tick-Borne Diseases, Ehrlichiosis
Necrotizing Fasciitis
Tick-Borne Diseases, Rocky Mountain Spotted Fever
Pediatrics, Chicken Pox or Varicella
Toxic Epidermal Necrolysis
Pediatrics, Kawasaki Disease
Pediatrics, Scarlet Fever
Rubella (German Measles)

Other Problems to Be Considered

Rocky Mountain spotted fever, hepatitis B, antinuclear antibody, syphilis, or acute mononucleosis, other viral exanthems, erysipelas, disseminated cellulitis
Pneumococcal sepsis
Sepsis of other causes 
Drug rash with high fever
Necrotizing fasciitis (This is also a GAS infection but requires immediate surgical debridement.)
Other invasive GAS

Workup

Laboratory Studies

None of the tests below are definitive, but results may typically show the following findings: 

  • CBC
    • High WBC, with a large proportion of immature forms (77% of cases)
    • Mild anemia with abnormal cells on smear
    • Thrombocytopenia
  • Electrolyte panel
    • Hyponatremia, hypokalemia, hypocalcemia out of proportion to hypoalbuminemia, hypophosphatemia, and hypomagnesemia
  • Renal function tests
    • Acute renal failure manifested by creatinine or BUN at least twice the upper limit of normal for laboratory (or doubling from the patient’s recent pre-illness norm)
    • GFR <50
  •  Liver function tests
    • Hyperbilirubinemia (76% of cases)
    • Aspartate aminotransferase (AST) level at least twice the upper limit of normal for laboratory (or doubling from the patient’s recent pre-illness norm) is found in 75% of cases.
    • Alanine aminotransferase (ALT) levels at least twice the upper limit of normal for laboratory (or doubling from the patient’s recent pre-illness norm) is found in 50% of cases.
  • Urine analysis
    • Sterile pyuria (greater than or equal to 5 leukocytes per high-power field)
    • Myoglobinuria
    • Protein, glucose, and red cell casts
  • Cultures
    • Positive blood cultures are not required to make the diagnosis but, when positive, are helpful at guiding antibiotic therapy. Positive staphylococcal blood cultures are only found in 5% of cases. More than 50% of patients with streptococcal TSS have a positive blood culture result.


Group A streptococci cause beta hemolysis on bloo...

Group A streptococci cause beta hemolysis on blood agar.

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Group A streptococci cause beta hemolysis on bloo...

Group A streptococci cause beta hemolysis on blood agar.

 

    • Culture all potentially infected sites. Group A streptococci may be isolated from a normally sterile site (eg, blood, cerebrospinal fluid [CSF], surgical wound). Isolation of GAS from a nonsterile site (eg, throat) does not confirm the diagnosis but may strengthen suspicion.
    • Although not strictly a culture, the rapid streptococcal test can be performed in 10-15 minutes and has a sensitivity of 87-95%.
  • Arterial blood gas analysis
  • Serologic tests
    • Results should show absence of serologic evidence of acute Rocky Mountain spotted fever, leptospirosis, measles, German measles, hepatitis B, antinuclear antibody, syphilis, or acute mononucleosis.
    • Creatine phosphokinase or myoglobin levels may indicate rhabdomyolysis (63% of cases).
    • Lactate level is often used in diagnosing septic shock. It may be included in a "full" blood gas. Monitoring lactate levels may assist in evaluating prognosis.34
    • VDRL test and Monospot can also be obtained.
  • Coagulation studies
    • Activated partial thromboplastin time (aPTT) (46% of cases) and fibrin split products are elevated.
    • Fibrinogen levels and prothrombin time (PT) usually are normal.
  • Miscellaneous
    • ProCalcitonin may be helpful in predicting septic multiorgan failure.35
    • C-reactive protein (CRP) level is usually elevated, and its rise parallels the rise in brain natriuretic peptide (BNP), but CRP has not been shown superior to WBC count in diagnosing TSS, and it does not independently predict mortality.
    • BNP has been proposed as a biomarker in sepsis, but it has not been validated.

Imaging Studies

Imaging studies are primarily helpful in ruling out other illnesses.

  • Chest radiographs may show pulmonary edema or ARDS. Sometimes, pneumonia can be the inciting factor for TTS; the presence of pneumonia does not rule out TTS.
  • Abdominal or extremity radiographs may show air if necrotizing fasciitis is present, or an embedded foreign body may be found.
  • Ultrasonography may be more effective in finding free air or embedded radiolucent foreign body.
  • CT scan may be more effective than plain radiography in identifying abscess or air in tissues.
  • MRI may show multiple areas of ischemic injury as in other shock syndromes.
  • Echocardiography may show wall-motion abnormality suggestive of toxic cardiomyopathy.

Other Tests

  • The ECG may show the following:
    • Tachycardia
    • Ventricular arrhythmias
    • Bundle-branch blocks
    • First-degree heart block
    • ST-T–wave changes, with ischemia

Procedures

  • Hemodynamic monitoring is mandatory. This may include arterial pressure line, cardiac monitoring, and continuous percutaneous O2 and CO2 monitoring.
  • Lumbar puncture should be performed if the diagnosis is in question and meningitis is considered. Findings should be normal in TSS. Cultures growing S aureus do not rule out TTS.
  • Patients may require large volumes of fluids for resuscitation, along with transduction of central venous pressures to guide management and pressors. Thus, central venous access may be indicated.
  • Echocardiography may be useful in the ICU setting. Many patients will have hypokinesis of the ventricular wall, and echocardiography may help guide management of associated cardiac failure.

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
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Further Reading

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Keywords

toxic shock syndrome, TSS, toxic shock, toxins, endotoxin, exotoxin,  toxin-1, TSST-1, Streptococcus pyogenes exotoxin A, SPEA, S pyogenes exotoxin B, SPEB, streptococcal TSS, staphylococcal TSS, streptococcal toxic shock syndrome, staphylococcal toxic shock syndrome, pyrogenic toxin superantigens, pyrogenic toxin super-antigens, menstrual toxic shock, non-menstrual toxic shock

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Contributor Information and Disclosures

Author

Vicken Y Totten, MD, MS, FACEP, FAAFP, Assistant Professor, Case Western Reserve University School of Medicine; Director of Research, Department of Emergency Medicine, University Hospitals, Case Medical Center
Vicken Y Totten, MD, MS, FACEP, FAAFP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Theodore J Gaeta, DO, MPH, FACEP, Clinical Associate Professor, Department of Emergency Medicine, Joan and Sanford Weill Medical College at Cornell University; Vice Chairman and Program Director of Emergency Medicine Residency Program, Department of Emergency Medicine, New York Methodist Hospital; Academic Chair, Adjunct Professor, Department of Emergency Medicine, St George's University School of Medicine
Theodore J Gaeta, DO, MPH, FACEP is a member of the following medical societies: Alliance for Clinical Education, American College of Emergency Physicians, Clerkship Directors in Emergency Medicine, Council of Emergency Medicine Residency Directors, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark L Plaster, MD, JD, Executive Editor, Emergency Physicians Monthly
Mark L Plaster, MD, JD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: M L Plaster Publishing Co LLC Ownership interest Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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