Toxic shock syndrome

Rare, life‑threatening shock syndrome caused by superantigen‑producing Staph aureus (TSST‑1 toxin) or Strep pyogenes (Spe exotoxins). Characterized by sudden high fever, hypotension, a diffuse erythroderma (sunburn‑like rash with later desquamation), and rapid multi‑organ failure.

• Rapidly fatal if unrecognized (mortality can exceed 30% in streptococcal cases). Classic exam scenario linking tampon use or post‑surgical wounds to shock and rash. Requires urgent source control and ICU care to prevent death.

• Menstruation-associated (Staph) TSS: classically a young woman using tampons → abrupt onset high fever (≥39 °C), headache, vomiting/diarrhea, diffuse sunburn-like rash, conjunctival injection, and hypotension.
• Non-menstrual TSS: any skin or soft-tissue infection (nasal packing, postpartum infection, surgical wound, burn) can serve as a source → similar presentation of fever + rash + shock. Often with mucous membrane hyperemia ("strawberry tongue"), and rash desquamates 1–2 weeks later.
• Streptococcal TSS (STSS) typically follows invasive GAS infection (e.g., necrotizing fasciitis or toxic strep cellulitis). Presents with severe localized pain, rapidly progressive infection, and early shock; blood cultures are often positive for GAS (unlike Staph TSS).

1. Immediately perform source control: remove any retained foreign body (tampon, nasal packing) and drain or surgically debride any infected wound or necrotic tissue.
2. Supportive care for shock: aggressive IV fluids, oxygen, and vasopressors as needed; monitor in ICU for multiorgan dysfunction (renal failure, ARDS, DIC, etc.).
3. Empiric broad-spectrum antibiotics: cover MRSA and GAS (e.g., vancomycin + clindamycin; add gram-negative coverage like piperacillin-tazobactam if polymicrobial infection is suspected). Clindamycin is crucial to inhibit toxin production.
4. Confirm diagnosis by CDC criteria (fever, rash, hypotension plus ≥3 organ systems involved). Streptococcal TSS is confirmed by isolation of GAS (usually from a sterile site). Do not wait for cultures—treat immediately if TSS is suspected.

1. Resuscitation: IV fluids (crystalloids) and support of blood pressure (add norepinephrine or other vasopressors if needed); ICU-level monitoring.
2. Remove the source: promptly take out tampons, vaginal diaphragms, nasal packing; obtain surgical consult for debridement of any necrotic infection (e.g., necrotizing fasciitis).
3. Empiric antibiotics: start broad IV coverage (e.g., vancomycin + clindamycin, plus a beta-lactam for gram-negatives if indicated) after obtaining cultures. Clindamycin helps suppress toxin production.
4. Tailor therapy once organism is identified: for GAS, use penicillin G + clindamycin; for MSSA, use nafcillin (or oxacillin) + clindamycin. Treat for about 10–14 days total.
5. Consider IVIG (2 g/kg) as adjunct therapy in severe cases refractory to fluids and vasopressors, to help neutralize circulating toxins.

• Mnemonic: TSS = Tampons → Staph → Shock (classic context for staphylococcal TSS in exams).
• TSS rash looks like a sunburn and later peels on palms/soles. Also remember strawberry tongue (as seen in scarlet fever and Kawasaki) — shock differentiates TSS.

• High fever, diffuse rash, and hypotension in a menstruating patient → suspect TSS immediately (remove tampon and begin empiric treatment).
• Severe pain out of proportion in a limb wound or postpartum infection with rapid progression to shock → consider GAS necrotizing infection causing TSS (emergency surgical intervention needed).

1. Shock with rash → suspect TSS; begin IV fluids, draw labs/cultures, and remove any foreign body (tampon, packing) immediately.
2. Start broad-spectrum antibiotics (vancomycin + clindamycin ± gram-negative coverage) without delay; send cultures from blood and infection sites.
3. Admit to ICU for invasive monitoring and supportive care; evaluate for organ failures (dialysis for kidney failure, mechanical ventilation for ARDS, correct coagulopathy, etc.).
4. If GAS is confirmed, switch to penicillin G plus clindamycin; pursue prompt surgical debridement of infected tissue (source control).
5. Add IVIG for patients in persistent shock despite fluids and vasopressors. Continue intensive supportive care until hemodynamically stable.

• Young woman on her period (tampon use) with sudden fever >102 °F, hypotension, vomiting, and a diffuse erythematous rash → Staphylococcal TSS (TSST‑1 from S. aureus).
• Patient with rapidly spreading soft-tissue infection (necrotizing fasciitis) who develops severe pain, hypotension, and multi‑organ failure → Streptococcal TSS (GAS invasive infection).