DESCRIPTION

Toxic shock syndrome (TSS) is an acute febrile illness characterized by hypotension and gastrointestinal and respiratory distress progressing to multisystem organ failure. The clinical syndrome is caused by bacterial exotoxins produced by the following:

• Staphylococcus aureus TSS toxin-1 (TSST-1)–producing strains, referred to as TSS in this section
• Group A β-hemolytic streptococci (GAS or Streptococcus pyogenes), referred to as streptococcal toxic shock–like syndrome (STSS) in this section
• Rare cases have also been reported in association with groups B, C, and G1 streptococci and Streptococcus mitis.

EPIDEMIOLOGY

• TSS can be related to focal infections or retained foreign bodies.
  • Previously linked to superabsorbent tampon use; menstrual-related TSS declined after increased public awareness.
  • Currently, ~50% of cases are nonmenstrual related.
• STSS incidence is highest among young children.
  • Associated with focal infections, pneumonia, or bacteremia
  • Higher prevalence of STSS in developing countries
• Generally rare; sporadic cases affect <1 people per 100,000 per year.

RISK FACTORS

• Local or invasive staphylococcal or streptococcal infection including sinus, skin, soft tissue, and musculoskeletal and respiratory infections
  • STSS most often occurs with skin and soft tissue infections, with preceding varicella infection being a known risk.
• Prolonged use of superabsorbent tampon, diaphragm, or contraceptive sponge
• Recent surgical or gynecologic procedure or postpartum wounds

GENERAL PREVENTION

• Scrupulous wound care
• Strict adherence to manufacturer’s directions for tampons and other intravaginal devices
• Early recognition and appropriate treatment of infections

PATHOPHYSIOLOGY

• Both S. aureus and S. pyogenes can produce exotoxins.
• Some exotoxins function as superantigens, interacting with immune cells to induce massive cytokine production leading to the predominant symptoms.
• Cytokines result in the hallmark findings of shock including fever, capillary leak, hypotension, and end-organ dysfunction.