Toxic Shock Syndrome Workup

Updated: Sep 13, 2017
  • Author: Ramesh Venkataraman, MBBS; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM  more...
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Workup

Laboratory Studies

CBC count with differential should be performed to determine the following:

  • Leukocytosis with a polymorphonuclear shift to the left
  • Mild leukocytosis with significant immature neutrophils on peripheral smear

Urinalysis should be performed to determine the following:

  • Myoglobinuria and hemoglobinuria present
  • Sterile pyuria

Prolonged prothrombin and activated partial thromboplastin times should be performed.

Serum biochemistry should be performed to determine the following:

  • 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 necrotizing fascitis, elevated serum creatinine kinase concentration

Blood cultures should be performed to determine the following:

  • Blood cultures positive for bacteria - Present in approximately 60% of the cases of disease associated with GAS
  • Compared with STSS, blood cultures rarely positive for staphylococci

Gram stain and cultures should be performed to determine the following:

  • 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 TSS include the following [10] :

  • 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%)

The case definition of streptococcal  toxic shock syndrome (TSS) involves (1) the isolation of group A Streptococcus (GAS) from either a sterile body site or a nonsterile body site and (2) a determination the clinical severity based on whether hypotension is present and the presence/absence of the following clinical and laboratory abnormalities:

  • Renal impairment
  • Coagulopathy
  • Liver abnormalities
  • Acute respiratory distress syndrome
  • Extensive tissue necrosis (ie, necrotizing fasciitis)
  • Erythematous rash

A definite case of TSS is defined as isolation of GAS from a sterile site and hypotension plus two or more of the clinical and laboratory abnormalities.

A probable case of TSS is defined as isolation of GAS from a nonsterile body site and hypotension plus two or more of the clinical and laboratory abnormalities.

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Imaging Studies

With regard to chest radiography, patients who develop multiorgan dysfunction have bilateral airspace infiltrates consistent with acute respiratory distress syndrome.

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