Toxic shock syndrome due to staphylococci (without MRSA)

Todd et al. 1978

Toxic shock syndromes, TSS, toxin shock syndrome, tampon disease.

Disease caused by superantigen-producing staphylococci with scarlatiniform exanthema and reduced general condition. In the course, it can lead to shock and multi-organ failure.

• Incidence: 0.8-3.4/100,000 (2000-2003)
• Current incidence is expected to remain stable
• About half of all TSS caused by staphylococci are NM-STSS
• Initially, M-STSS was particularly prevalent. Since patients are now educated about the regular exchange of tampons and there have also been changes in manufacturing, the rate of "tampon-triggered" toxic shock syndromes has decreased

• Nonmenstruation-associated staphylococcal-induced toxic shock syndrome (NM-STSS)
• Menstruation-associated staphylococcal-induced toxic shock syndrome (M-STSS)

• NM-TSS is mainly caused by staphylococci of the skin (wounds, abscesses, boils), in the setting of another gynaecological infection (e.g. postpartum), burns, sinusitis, osteomyelitis or arthritis, respiratory tract infections following influenza infection, enterocolitis and i.v. drug abuse
• Staphylococci produce exotoxins such as Toxic Shock Syndrome Toxin-1 (TSST-1) and Staphylococcal Enterotoxins B, C, D, E and H. All of these toxins are superantigens and can activate high numbers of T lymphocytes, which then release exceptionally high numbers of proinflammatory cytokines
• The immune system, as with all infections, is quite important. Patients without TSST-1 neutralising antibodies are far more likely to develop TSS than other patients

• Initial symptoms include fever, pharyngitis, myalgias, diarrhoea, vomiting. A macular, scarlatiniform, generalised exanthema is seen. Palmoplantar erythema may be seen. After 1-2 weeks, desquamation occurs. Invariably, conjunctival hyperaemia, pharyngitis and 'strawberry tongue' are seen. In some cases, CNS symptomatology can be elicited.
• The hypotension associated with TSS is manifested by an exanthema prominent on the trunk, orthostatic dysfunction and shock with multiorgan failure
• Often, early treatment results in less severe symptoms
• The average time between the onset of menstruation and TSS is 2-3 days, often only 2 days after surgery, but TSS can still occur after 2 months

Clinical criteria (United States Centers for Disease Control and Prevention):

• Fever: temperature ≥ 38.9°C
• Blood pressure: Systolic blood pressure ≤ 90 mmHg (adults), less than the 5th percentile for children under 16 years of age
• Skin lesion: Diffuse, macular (scalatiniform) exanthema
• Scaling: 1-2 weeks after onset of disease, especially palmoplantar
• Multiorgan system (involvement of ≥ 3 systems)
• Gastrointestinal: vomiting, diarrhoea
• Muscular: myalgias, ≥ 2-fold elevated CK
• Mucosal: Vaginal, oropharyngeal and hyperaemia of the conjunctiva
• Renal: urea or creatinine ≥ 2-fold elevation
• Liver: bilirubin or transaminases ≥ 2-fold elevation
• Hematological: <100000 platelets
• NSNS: disorientation, altered consciousness without focal neurological signs without fever or hypotension
• No other evidence of germs (except possibly Staphylococcus aureus, but evidence of S. aureus is not essential to make the diagnosis)
• Negative serological test (antibodies are often only determined in special laboratories) for Rocky Mountain spotted fever, leptospirosis or measles

• Clinic
• Bacterial smears (where focus is suspected: neck, vagina, skin lesions, nasal vestibule, groin). S. aureus can be isolated from the suspected focus in 80-90% of cases, but serological detection is possible in only 5% of cases
• Blood count (anaemia, leukocytosis with neutrophilia, thrombocytopenia), coagulation (consumptive coagulopathy, prolonged prothrombin time and partial thromboplastin time), creatinine, urea (renal insufficiency), transaminases, bilirubin (hepatic insufficiency), creatinine kinase (myalgia) , electrolytes (hyponatremia, hypalbuminemia, hypocalcemia, hypophosphatemia)
• Blood culture (pathogen detection), U status
• In case of CNS symptomatology (encephalopathy with disorientation, confusion, epileptic seizures, cerebral oedema, headache, memory loss, poor concentration): Neurological consultation and CSF sampling
• For respiratory problems: Chest X-ray and internal medicine consultation if necessary
• Exclusion of a vaginal/intrauterine foreign body
• Vital parameter monitoring

• Lethality ranges from 1.8-6%
depending on the trigger and study
• Women with M-STSS should stop using tampons. IUDs for contraception should also be avoided
• Recurrences occur days to months after the initial manifestation in patients who have not received adequate antibiotic treatment, do not produce the body's own antibodies and where the cause (the focus of the infection) has not been remediated

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