eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Toxic Shock Syndrome: Differential Diagnoses & Workup

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California at Los Angeles; Professor of Medicine, Charles R Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Contributor Information and Disclosures

Updated: Jan 27, 2009

Differential Diagnoses

Ehrlichiosis
Measles
Hantavirus Pulmonary Syndrome
Meningococcal Infections
Kawasaki Disease
Rocky Mountain Spotted Fever
Leptospirosis
Systemic Lupus Erythematosus

Other Problems to Be Considered

Adenovirus infection
Drug eruption
Erythema multiforme
Toxic epidermal necrolysis

Workup

Laboratory Studies

Microbiologic studies should be performed to recover the organisms from appropriate samples, such as blood, surgical wounds, vagina, throat, or soft tissue aspirates.

  • In a review of staphylococcal toxic shock syndrome (TSS) by Davis and colleagues, the frequencies of abnormal laboratory results were as follows:2
    • Elevated serum creatinine levels - 69%
    • Thrombocytopenia - 59%
    • Hypocalcemia - 58%
    • Azotemia - 57%
    • Hyperbilirubinemia - 54%
    • Elevated levels of hepatic enzymes - 50%
    • Leukocytosis - 48%
    • Abnormal urinary sediment - 46%
    • Elevated creatine kinase levels - 41%
    • Immature leukocytes - 36%
  • Laboratory findings in patients with streptococcal toxic shock syndrome include the following:
    • Elevated serum creatinine levels
    • Hemoglobinuria
    • Hypoalbuminemia
    • Hypocalcemia
    • Elevated creatine kinase levels (suggesting necrotizing fasciitis or myositis)
    • Leukocytosis (with increased band forms)
    • Blood cultures (positive results in 60% of patients)
  • Coagulation studies should be obtained, including prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen split products, and D-dimer.
  • If CNS infection is possible, the CSF should be analyzed and cultured.
  • Appropriate serologic analysis may be necessary to evaluate other possible differential diagnoses.

Imaging Studies

  • Soft tissue radiography, CT scanning, or MRI may help delineate the deeper tissue involvement in patients with necrotizing fasciitis and streptococcal toxic shock syndrome.

Procedures

  • If meningitis is possible, lumbar puncture should be performed to sample CSF for appropriate studies.

Histologic Findings

  • Histopathologic findings in patients with staphylococcal toxic shock syndrome include desquamation of vaginal and cervical mucosa, periportal hepatic inflammation, acute tubular necrosis, and the abnormal pulmonary findings of acute respiratory distress syndrome (ARDS).

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, acute respiratory distress syndrome, conjunctival hyperemia, cyanosis, endophthalmitis, erythroderma, hypotension, leptospirosis, measles, menses, menstruation, myocarditis, myositis, perihepatitis, peritoneal effusions, peritonitis, pleural effusions, Rocky Mountain spotted fever, soft tissue necrosis, staphylococcal infection, staphylococcal TSS, Staphylococcus aureus, S aureus, streptococcal infection, streptococcal TSS, Streptococcus pyogenes, S pyogenes, tampon use, TSS toxin-1, TSST-1, vaginal hyperemia

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Vinod K Dhawan, MD, FACP, FRCP(C), Professor, Department of Clinical Medicine, University of California at Los Angeles; Professor of Medicine, Charles R Drew University of Medicine and Science; Chief, Division of Infectious Diseases, MLK-Harbor Hospital
Vinod K Dhawan, MD, FACP, FRCP(C) is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada
Disclosure: Pfizer Inc None None

Medical Editor

David Jaimovich, MD, Chief Medical Officer, Joint Commission International and Joint Commission Resources
David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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