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Toxic Shock Syndrome

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Toxic Shock Syndrome (TSS) is a life-threatening condition that requires immediate recognition and management. Patients can deteriorate rapidly, sometimes within hours. It is often seen in children or young adults following a minor skin wound, surgical site infection, or tampon use due to a superantigen. Early volume resuscitation and broad-spectrum antibiotics are crucial. Always assess for signs such as rash, diarrhoea, hypotension, and altered mental status. If TSS is suspected, administer fluids immediately, initiate empirical antibiotics, and seek urgent medical support, including ICU transfer.

Initial Shock Management: Oxygen 15 L/min (unless contraindicated, e.g., COPD)
ABC approach: Secure airway, ensure adequate breathing, and stabilize circulation. IV Access: Establish two large-bore IV lines and start IV normal saline (20 mL/kg bolus) rapidly. Empirical Antibiotics: Administer broad-spectrum IV antibiotics as soon as possible, covering gram-positive and gram-negative bacteria (e.g., clindamycin, vancomycin, piperacillin-tazobactam). Eliminate Toxin Source: Remove retained tampons, nasal packing, or debride infected wounds. Monitoring and Labs: Send FBC, U&E, LFT, Group and Hold, Lactate, Troponin, D-dimer, and ABG. Urine Output: Consider placing a urinary catheter to monitor urine output and assess renal function. Indicators of Severity: Watch for fever, hypotension, sepsis signs, rash, and elevated lactate levels. IVIG Consideration: Administer IV immunoglobulin (IVIG) in severe cases to neutralize toxins and modulate immune response. ICU Referral: Early transfer to ICU for advanced monitoring and support, including potential vasopressors.

Initial Shock Management: Oxygen 15 L/min (unless contraindicated, e.g., COPD)

ABC approach: Secure airway, ensure adequate breathing, and stabilize circulation.
IV Access: Establish two large-bore IV lines and start IV normal saline (20 mL/kg bolus) rapidly.
Empirical Antibiotics: Administer broad-spectrum IV antibiotics as soon as possible, covering gram-positive and gram-negative bacteria (e.g., clindamycin, vancomycin, piperacillin-tazobactam).
Eliminate Toxin Source: Remove retained tampons, nasal packing, or debride infected wounds.
Monitoring and Labs: Send FBC, U&E, LFT, Group and Hold, Lactate, Troponin, D-dimer, and ABG.
Urine Output: Consider placing a urinary catheter to monitor urine output and assess renal function.
Indicators of Severity: Watch for fever, hypotension, sepsis signs, rash, and elevated lactate levels.
IVIG Consideration: Administer IV immunoglobulin (IVIG) in severe cases to neutralize toxins and modulate immune response.
ICU Referral: Early transfer to ICU for advanced monitoring and support, including potential vasopressors.

About TSS

TSS is an acute, non-contagious systemic illness caused by bacterial exotoxins acting as superantigens.
It can present with a rapid onset and progress to severe shock, leading to multi-organ failure and death if untreated.
Commonly associated with menstruating females using tampons, TSS can also occur after skin injuries, surgical wounds, or nasal packing.
Mortality rates can be reduced with early recognition and aggressive management, typically estimated around 2.5% with timely intervention.

Epidemiology

TSS is a rare but serious condition, with an estimated incidence of 1-3 cases per 100,000 people per year.
It occurs in all age groups, with peak incidence among menstruating women due to tampon use, but can also affect children, older adults, and males.
Staphylococcal TSS is more common, but streptococcal TSS (often from Group A Streptococcus) tends to be more severe with higher mortality.

Aetiology

Etiology	Pathophysiology
Staphylococcus aureus	Staph aureus produces toxic shock syndrome toxin-1 (TSST-1) and other enterotoxins that act as superantigens. These toxins bypass normal immune regulation, leading to widespread T-cell activation and a cytokine storm. This inflammatory response results in severe hypotension, capillary leak, and multi-organ dysfunction.
Streptococcus pyogenes (Group A Streptococcus)	Strep pyogenes produces streptococcal pyrogenic exotoxins (SPEs), which also act as superantigens, causing a similar immune response as seen in staphylococcal TSS. It is often associated with severe soft tissue infections like necrotizing fasciitis, resulting in more aggressive clinical symptoms and higher mortality.
Other Bacterial Causes	Less commonly, TSS can be triggered by other bacterial species or mixed infections, especially in the context of surgical wounds or post-childbirth infections. These bacteria may produce superantigenic toxins that cause systemic inflammation, cytokine release, and shock.

Risk Groups

Females using tampons, particularly high-absorbency ones.
Individuals with recent skin wounds, surgical sites, or burns.
Postoperative patients, including those with retained surgical packing.
Children and adults with recent varicella (chickenpox) or other viral infections.
Individuals with compromised immune systems or chronic illnesses.

Case Definition

Criteria	Description
Fever	Temperature ≥38.9°C (≥102°F).
Rash	Diffuse macular erythema (red rash) that may resemble sunburn, often followed by desquamation (peeling of skin) on palms and soles within 1-2 weeks.
Hypotension	Systolic blood pressure ≤90 mmHg in adults, or hypotension relative to age norms in children, often accompanied by dizziness or syncope.
Multiorgan Involvement	At least three of the following systems affected: Gastrointestinal: Severe vomiting or diarrhoea at the onset. Muscular: Myalgia (muscle pain) or elevated creatine kinase (≥2x upper limit). Mucous Membranes: Redness of the eyes (conjunctivae), throat (oropharynx), or vagina. Renal: Elevated BUN or creatinine levels (≥2x normal), or sterile pyuria. Hepatic: Elevated liver enzymes (AST, ALT) or bilirubin. Haematologic: Thrombocytopenia (platelet count <100,000/mm³). CNS: Altered mental state without other neurologic causes.
Exclusion of Other Diseases	No other confirmed diagnosis that explains the clinical presentation (e.g., measles, leptospirosis, RMSF).
Laboratory Criteria	Isolation of Staphylococcus aureus or Streptococcus pyogenes from normally sterile sites like blood or cerebrospinal fluid.

Management

Cause	Description	Management
Staphylococcus aureus	Most common cause of TSS, often linked to tampon use, surgical wounds, and skin infections.	Immediate removal of the source (e.g., tampon, surgical packing). Aggressive IV fluid resuscitation to correct hypotension. Empiric antibiotic therapy (e.g., clindamycin with vancomycin or linezolid). IV immunoglobulin (IVIG) to neutralize toxins. Supportive care in ICU with vasopressors if needed.
Streptococcus pyogenes	Commonly associated with skin infections like necrotizing fasciitis.	Surgical debridement of infected tissues is critical. IV fluids and antibiotics (e.g., penicillin and clindamycin). Consider IVIG for toxin neutralization in severe cases. Intensive monitoring for organ dysfunction in ICU.
Other Causes	Includes mixed infections or post-surgical contamination.	Identification and removal of the infectious source. Targeted antibiotic therapy guided by cultures. IV fluid resuscitation and haemodynamic support. Management of complications like acute kidney injury or respiratory failure. Close monitoring in ICU.

References

Recognition and Management of Toxic Shock Syndrome (TSS)
Toxic Shock Syndrome Information
Fisher MC, et al. Clinical features of staphylococcal and streptococcal TSS. JAMA. 2019;321(6):588-598.

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