Toxic shock syndrome

Toxic shock syndrome (TSS) is an exotoxin-mediated disease caused by 2 bacterial infections (most commonly):

1. Staphylococcus aureus (both MSSA and MRSA)
2. Group A streptococcus (strep. pyogenes)

It causes an exaggerated inflammatory response due to inflammatory cytokines → shock and multi-organ failure.

Staphylococcal TSS

The toxin from the staphylococcus aureus that causes TSS are:

• Enterotoxins A, B, C
• TSST-1 superantigen

Staphylococcal TSS can be subdivided into 2 further types:

1. Menstrual TSS - as the name implies, it occurs in menstruating women due to the extended use of a single tampon or due to highly-absorbable tampons (but this is more historically accurate)
2. Non-menstrual TSS - occurs post-partum due to vaginal/caesarean wound infections.

Streptococcal TSS

The toxin from streptococcus pyogenes that causes TSS is the:

• Streptococcal toxic shock syndrome toxin (STSS toxin)

It can occur at any infectious site. The most common sites are skin, vagina and pharynx. However, in many cases, no site of entry is found.

The presentation of TSS may be non-specific/flu-like symptoms (e.g. fever, chills, myalgia, headache).

• Severe diffuse/localised pain in an extremity is the most common presentation of streptococcal disease is
• However, the disease course is very steep and can result in high-grade fever (>38.9ºC) and widespread, macular rash (red and flat) very quickly. This rash often covers >90% of the body surface (including mucosal membranes).
• Shock (BP <90mmHg) and multi-organ failure follows, along with encephalopathy and confusion.
• Peeling (desquamation) of the rash, especially on the palms and soles of the feet are also commonly seen as late presentations.

Multi-organ failure may include:

1. Renal failure
2. Hepatitis
3. Thrombocytopenia
4. Encephalopathy
5. Diarrhoea and vomiting