ICU · Infectious Diseases
Toxic shock syndrome in the ICU
Also known as Toxic shock syndrome (TSS) · Staphylococcal TSS · Streptococcal TSS (STSS) · Superantigen-mediated disease
Toxic shock syndrome (TSS) is a life-threatening toxin-mediated illness caused by SUPERANTIGEN-producing bacteria. STAPHYLOCOCCAL TSS: Staphylococcus aureus TSST-1 toxin from a localised mucosal or wound focus. STREPTOCOCCAL TSS: Streptococcus pyogenes (GAS) superantigens such as SpeA from invasive soft-tissue infection. Superantigens bypass normal MHC-restricted antigen presentation and directly engage MHC class II and the T-cell receptor, activating large numbers of T cells and releasing a cytokine avalanche that causes fever, vasodilatory shock, disseminated intravascular coagulation and multi-organ failure. Management: (1) Source control (remove tampon or packing, drain and debride infected tissue). (2) Antibiotics that suppress toxin production (clindamycin or linezolid) PLUS a cell-wall agent (anti-staphylococcal penicillin or cephalosporin, vancomycin where MRSA is prevalent). (3) Adjunctive high-dose IVIG in severe streptococcal TSS. (4) Aggressive organ support.
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Red flags
- HIGH fever + HYPOTENSION + DIFFUSE RASH + MULTI-ORGAN failure = TSS until proven otherwise
- Streptococcal TSS mortality 30 percent in the founding series — MUCH higher than staphylococcal (one death among seven founding cases)
- Clindamycin SUPPRESSES TOXIN PRODUCTION — give it EARLY in addition to a cell-wall antibiotic
- IVIG neutralises superantigen — associated with improved survival in severe streptococcal TSS
Meet the patient
A 19-year-old woman is admitted in septic shock four days into her period, a super-absorbent tampon still in situ. She is febrile, vomiting, sunburn-red from head to toe including her palms and soles, confused, and her blood pressure will not hold. Blood cultures will be negative.[1][2]
Two questions decide the next hour and they decide every TSS: what is the source of the toxin (find it and remove it now), and have I given a toxin-suppressing antibiotic yet (the protein-synthesis inhibitor that stops the toxin being made). Hold those two and the whole disease slots into place.[1][10]
References15ShowHide
- [1]Todd J, Fishaut M, Kapral F, Welch T Toxic-shock syndrome associated with phage-group-I Staphylococci Lancet, 1978.PMID 82681
- [2]Shands KN, Schmid GP, Dan BB, et al. Toxic-shock syndrome in menstruating women: association with tampon use and Staphylococcus aureus and clinical features in 52 cases N Engl J Med, 1980.PMID 7432402
- [3]Kass EH, Schlievert PM, Parsonnet J, Mills JT Effect of magnesium on production of toxic-shock-syndrome toxin-1: a collaborative study J Infect Dis, 1988.PMID 3134495
- [4]Stevens DL, Gibbons AE, Bergstrom R, Winn V The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis J Infect Dis, 1988.PMID 3292661
- [5]Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A N Engl J Med, 1989.PMID 2659990
- [6]The Working Group on Severe Streptococcal Infections Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition JAMA, 1993.PMID 8418347
- [7]Zimbelman J, Palmer A, Todd J Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection Pediatr Infect Dis J, 1999.PMID 10608632
- [8]Darenberg J, Ihendyane N, Sjölin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial Clin Infect Dis, 2003.PMID 12884156
- [9]Fraser JD, Proft T The bacterial superantigen and superantigen-like proteins Immunol Rev, 2008.PMID 18837785
- [10]Lappin E, Ferguson AJ Gram-positive toxic shock syndromes Lancet Infect Dis, 2009.PMID 19393958
- [11]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America Clin Infect Dis, 2014.PMID 24947530
- [12]Linnér A, Darenberg J, Sjölin J, et al. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study Clin Infect Dis, 2014.PMID 24928291
- [13]Gottlieb M, Long B, Koyfman A The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature J Emerg Med, 2018.PMID 29366615
- [14]Laho D, Blumental S, Botteaux A, Smeesters PR Invasive Group A Streptococcal Infections: Benefit of Clindamycin, Intravenous Immunoglobulins and Secondary Prophylaxis Front Pediatr, 2021.PMID 34490159
- [15]Davis CC, Baccam M, Mantz MJ, et al. Use of porcine vaginal tissue ex-vivo to model environmental effects on vaginal mucosa to toxic shock syndrome toxin-1 Toxicol Appl Pharmacol, 2014.PMID 24333258