Chapter 59 Toxic Shock Syndrome
INTRODUCTION
Description: Toxic shock syndrome (TSS) is caused by toxins produced by an often asymptomatic infection with Staphylococcus aureus. Although most commonly associated with prolonged tampon use, about 10% of TSS cases are associated with other conditions.
Prevalence: Seen in 1 to 2 per 100,000 women 15 to 44 years of age (last active surveillance done in 1987).
ETIOLOGY AND PATHOGENESIS
Causes: S. aureus exotoxins (TSS toxin-1, enterotoxins A, B, and C). For toxic shock to develop, three conditions must be met: there must be colonization by the bacteria, it must produce toxin, and there must be a portal of entry for the toxin. The presence of foreign bodies, such as a tampon, is thought to reduce magnesium levels, which promotes the formation of toxin by the bacteria.
CLINICAL CHARACTERISTICS
Signs and Symptoms
• Most common—rapid onset of fever greater than 38.9°C (102°F), hypotension, diffuse rash (the rash caused by TSS is commonly absent in places where clothing presses tightly against the skin). Hypotension may progress to severe and intractable hypotension and multisystem dysfunction.
• Other typical findings—agitation; arthralgias; confusion; diarrhea; erythema of pharynx, vulva, or vagina; conjunctiva; headache; myalgias; nausea; vomiting
DIAGNOSTIC APPROACH
Differential Diagnosis
• Other exanthems (acute rheumatic fever, bullous impetigo, drug reaction, erythema multiforme, Kawasaki disease, leptospirosis, meningococcemia, Rocky Mountain spotted fever, rubella, rubeola, scarlet fever, viral disease)
• Gastrointestinal illness (appendicitis, dysentery, gastroenteritis, pancreatitis, staphylococcal food poisoning)
Associated Conditions: Other sources—surgical wounds (including dilation and curettage), nonsurgical focal infections, cellulitis, subcutaneous abscesses, mastitis, infected insect bites, postpartum (including transmission to the neonate), nonmenstrual vaginal conditions, vaginal infection, pelvic inflammatory disease, steroid cream use. Even the use of laminaria to dilate the cervix has been reported to be associated with rare cases.
