Toxic Shock Syndrome Clinical Presentation

Although the clinical manifestations of toxic shock syndrome (TSS) can be diverse, the possibility of toxic shock should be considered in any individual who presents with sudden onset of fever, rash, hypotension, renal or respiratory failure, and changes in mental status. ^[13]

Staphylococcal TSS (STSS) most commonly occurs in women, usually those who are using tampons, TSS develops within 5 days after the onset of menstruation. The other clinical settings where STSS has been reported include the following:

• Surgical wound infections

• Postpartum infections

• Focal cutaneous and subcutaneous lesions

• Deep abscesses

• Empyema

• Peritonsillar abscess

• Sinusitis

• Osteomyelitis

Soft tissue infections from group A Streptococcus (GAS) include necrotizing fasciitis, myositis, or cellulitis. The most common initial symptom of patients with streptococcal TSS is diffuse or localized pain that is abrupt and severe. Other manifestations include the following:

• Influenzalike syndrome

• Fever

• Confusion

• Signs of soft tissue infection

Approximately 20% of patients with STSS have an influenzalike syndrome characterized by the following:

• Fever

• Chills

• Myalgia

• Nausea

• Vomiting

• Diarrhea

The other reported types of infection are pneumonia, unidentified bacteremia, surgical site infection, septic arthritis, thrombophlebitis, meningitis, pelvic infection, and endophthalmitis.

Common presenting symptoms and frequency of STTS are as follows ^[11] :

• Pain (44-85%)

• Vomiting (25-26%)

• Nausea (20%)

• Diarrhea (14-30%)

• Influenzalike symptoms (14-20%)

• Headache (10%)

• Dyspnea (8%)

The following risk factors have been reported to be associated with STSS:

• Patients with HIV, diabetes, cancer, ethanol abuse, and other chronic diseases

• Patients with a recent history of varicella infection (chicken pox)

• Patients who used nonsteroidal anti-inflammatory drugs (NSAIDs)

Fever is the most common presenting sign, although patients in shock may present with hypothermia. Shock is apparent at the time of hospitalization or within 4-8 hours for all patients. Patients become severely hypotensive and do not respond to intravenous fluid administration. Renal dysfunction progresses or persists in all patients, precedes shock in many patients, and is apparent early. Acute respiratory distress syndrome occurs in 55% of patients and requires mechanical ventilation.

A thorough search for possible sites of streptococcal and staphylococcal infection is a must. The surgical wounds should be carefully examined even if no signs of infection are apparent. Vaginal examination and removal of tampon or other foreign body should be done diligently.

Confusion is present in 55% of patients, and coma or agitation may occur. Alteration in mental status disproportionate to the degree of hypotension can occur with or without seizures. Persistent neuropsychiatric sequelae manifested by memory loss, and poor concentration have been reported.

Nearly 50% of patients are normotensive on presentation but become hypotensive within 4 hours.

Approximately 80% of patients have clinical signs of soft tissue infection (eg, localized swelling, erythema), which usually progresses to necrotizing fasciitis or myositis.

Approximately 20% of patients have various clinical presentations, including the following:

• Endophthalmitis

• Myositis

• Perihepatitis

• Peritonitis

• Myocarditis

Diffuse scarlatinalike erythema occurs in 10% of patients. Skin manifestations of streptococcal infection include the following (also see images below):

• Bullae

• Scarlet fever–like rash

• Petechiae or maculopapular rashes

• Desquamation

  Progression of soft tissue swelling to vesicle or bullous formation is an ominous sign and suggests streptococcal shock syndrome. Courtesy of S. Manocha.

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  A 46-year-old man presented with nonnecrotizing cellulitis and streptococcal toxic shock syndrome. This patient also had streptococcal pharyngitis. Courtesy of Rob Green, MD.

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  A 46-year-old man presented with nonnecrotizing cellulitis and streptococcal toxic shock syndrome. The patient had diffuse erythroderma, a characteristic feature of the syndrome. Courtesy of Rob Green, MD.

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Mucosal involvement includes conjunctival/scleral hemorrhage and hyperemia of the vaginal and oropharyngeal mucosa. Petechial hemorrhages (“strawberry tongue”) and ulcerations of mucosal membranes can occur in severe cases. The possibility of STSS should be entertained in any patient who presents with a sudden onset of fever, rash, hypotension, and systemic evidence of toxicity. Five categories of clinical features are needed for the diagnosis (Centers for Disease Control and Prevention, 1990).

The five categories are (1) fever; (2) rash (diffuse macular erythroderma); (3) desquamation (1-2 wk after illness onset, involving palms and soles); (4) hypotension (systolic blood pressure < 90 mm Hg, orthostatic drop in diastolic blood pressure < 15 mm Hg, orthostatic syncope, and dizziness); and (5) evidence of multisystem involvement in 3 or more of the following systems:

• Gastrointestinal - Vomiting or diarrhea at the onset of illness

• Muscular - Severe myalgia or creatine kinase (CK) elevation (>2 times normal upper limit)

• Mucous membrane - Vaginal, oropharyngeal, or conjunctival erythema

• Renal - BUN or serum creatinine greater than 2 times the upper limit of normal

• Hepatic - Bilirubin or transaminases greater than 2 times the upper limit of normal

• Hematological - Platelets less than 100,000

• Central nervous system - Disorientation or alteration in consciousness without focal signs

Common presenting symptoms and frequency of STTS are as follows ^[6] :

• Tachycardia (80%)

• Fever (70-81%)

• Hypotension (44-65%)

• Confusion (55%)

• Localized erythema (44-65%)

• Localized swelling and erythema (30-75%)

• Scarlatiniform rash (0-4%)

The case definition of streptococcal TSS involves the isolation of GAS, hypotension, and multisystem involvement. ^[14]

The presence of hypotension (systolic pressure < 90 mm Hg in adults or less than fifth percentile for children) is required, along with either (1) the isolation of GAS (S pyogenes) from a normally sterile site (eg, blood, cerebrospinal fluid, pleural fluid) for a definite case or (2) the isolation of GAS (S pyogenes) from a nonsterile site for a probable case.

Additionally, multiorgan involvement, as evidenced by at least 2 of the following, is required for either definite or probable cases:

• Renal impairment - Creatinine level more than 177 µmol/L for adults or twice upper normal limit for age or more than twice the baseline level for patients with renal disease

• Coagulopathy - Platelet count less than 100 X 10⁶/L or disseminated intravascular coagulation

• Liver involvement - Alanine aminotransferase, aspartate aminotransferase, or total bilirubin level more than twice normal limit for age or more than twice baseline in patients with chronic liver disease

• Pulmonary involvement - Adult respiratory distress syndrome or evidence of diffuse capillary leak syndrome

• Generalized erythematous macular rash

• Soft tissue necrosis (necrotizing infection, necrotizing myositis, or gangrene)

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.