Dr Neha Bansal

What is toxic shock syndrome (TSS)?
It is a potential fatal infection resulting from a bacterial toxin.

What causes TSS?
It is caused by various organisms like Staphylococcus aureus and group A Streptococcus pyogenes.

What are the signs and symptoms of toxic shock syndrome?
The case definition requires all 3 manifestations of fever, hypotension and diffuse scarlatiniform rash (erythema, which blanches and desquamates one or two weeks after onset of illness). It presents with various signs of infection, hemodynamic dysfunction and organ failure. (2)

As per CDC (1), there should be involvement of more than 3 extra-cutaneous organs for a diagnosis. These include

	gastrointestinal (vomiting or diarrhea at onset of illness),
	muscular (severe myalgia or creatine phosphokinase level >2 times upper     normal limit),
	mucous membrane (vaginal, oropharyngeal or conjunctival hyperemia),
	renal (blood urea nitrogen or creatinine levels > 2 times upper normal limit     or > 5 leukocytes per high-power field-in the absence of a urinary tract     infection),
	hepatic (total bilirubin, serum asparate aminotransferase or serum alanine     aminotransferase levels >2 times upper normal limit),
	hematologic (platelets < 100,000 per cumm),
	central nervous system (disorientation or alterations in consciousness     without focal neurological signs when fever and hypotension are absent).

What Investigations are needed in toxic shock syndrome?
Various abnormal laboratory values are observed but they are non-specific. Leucocytosis, thrombocytopenia, elevated transaminases, azotemia, hematuria, pyuria are just some of the findings in most of the cases. (1) Negative results on the following tests: Blood, throat or cerebrospinal fluid cultures are often observed. Serological tests for Rocky Mountain spotted fever, leptospirosis or measles should be done to rule them out. (1)

What is the differential diagnosis of toxic shock syndrome?
TSS is most often seen in the menstruating women who use tampons. However, it is not uncommon in children. The milder form of the disease is often confused with Kawasaki disease and Scarlet fever. (1)

What is the treatment of toxic shock syndrome?
Treatment of TSS includes close monitoring of the patient along with elimination of the localized infection focus (skin or soft tissue). Supportive treatment should be started for any renal insufficiency and hypotension. (1)Supportive management is required in case of multiple organ failures. Antibiotics are used to eliminate staphylococcal or streptococcal infections which reduce mortality. Vancomycin and clindamycin are often used. (1, 2) Corticosteroids and IVIG may be useful. (3)

REFERENCES

1.		Ganem D. Toxic shock syndrome-Medical Staff Conference, University of California, San Francisco. West J Med 135:383-388, Nov 1981.
2.		Irazuzta J, Sullivan KJ, Garcia PC, Piva JP. Pharmacologic support of infants and children in septic shock. J Pediatr (Rio J). 2007;83(2 Suppl):S36-45.
3.		Masao Miyashita. Controversy of Corticosteroids in Septic Shock. J Nippon Med Sch 2010; 77: 67-70.