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Toxic Shock Syndrome and Streptococcal Toxic Shock Syndrome

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Title: Toxic Shock Syndrome and Streptococcal Toxic Shock Syndrome


1
Toxic Shock Syndrome and Streptococcal Toxic
Shock Syndrome
  • Dr. Batizy, D.O.
  • January 26, 2006

2
Toxic Shock Syndrome
  • Severe life threatening syndrome characterized
    by
  • High fevers
  • Severe hypotension
  • Diffuse erythroderma
  • Mucous membrane hyperemia
  • Pharyngitis
  • Diarrhea

3
Toxic Shock Syndrome
  • May progress rapidly
  • Multisystem disfunction
  • Severe electrolyte disturbances
  • Renal failure
  • Shock

4
Toxic Shock Syndrome
  • Discovered in 1978 in apparently healthy children
    Staph aureus isolated
  • TSS epidemic 1981 associated with increased
    tampon use
  • Incidence has dropped significantly,
  • Currently most cases are unrelated to menses
  • Case Definition of Toxic Shock Syndrome, table
    142-1

5
Case Definition of Toxic Shock Syndrome, Table
142-1
  • Fever temp gt102.0 F (gt38.9 C)
  • Rash diffuse macular erythroderma
  • Hypotension
  • Multisystem envolvement (three or more)
  • GI vomiting or diarrhea at onset of illness
  • Muscular sever myalgia or creatine phosphokinase
    level at least twice the upper limit of normal
  • Mucous membrane vaginal, oropharyngeal, or
    conjunctival hyperemia

6
  • Renal blood urea nitrogen or creatinine at least
    twice the upper limit of normal for laboratory or
    urinary sediment with pyuria (greater than or
    equal to 5 leukocytes per highpower field) in the
    absence of urinary tract infection
  • Hepatic total bilirubin, alanine
    aminotransferase enzyme, or asparate
    aminotransferase enzyme levels at least twice the
    upper limit of normal for laboratory
  • Hematologic platelets less than 100,000/ml

7
  • CNS disorientation or alterations in
    consciousness without focal neurologic signs when
    fever and hypotension are absent
  • Lab criteria negative results on the following
    tests, if obtained
  • Blood, throat, or cerebrospinal fliud cultures
    (blood culture may be positive for Staphlococcus
    aureus
  • Rise in titer to Rocky Mountain Spotted fever,
    leptospirosis, or measles

8
Case Definition of TSS
  • Case classification
  • Probable five of six clinical findings are
    present
  • Confirmed all six clinical findings are present,
    including desquamation, unless patient dies
    before desquamation occurs

9
Epidemiology
  • TSS initially a disease of young healthy
    menstruating women, comprised fifty percent of
    cases reported in 1986-87
  • Tampon use increased risk up to 33
  • In 2000, 135 reported cases, 3 were in men, and 2
    fatalities were from menstrual-related TSS
    (MRTSS)
  • FDA - Tampons now made of cotton and rayon,
    should be changed every 4-8 hrs

10
Epidemiology
  • Non-menstrual related cases of Toxic Shock
    Syndrome (NMTSS)
  • Increasing since 1980
  • 41 NMTSS
  • Men comprise one-tenth of population
  • Mortality rate 3.3 x that of MRTSS in women
  • S. aureus isolated from 98 of women with TSS
  • Women with MRTSS most likely colonized with Staph
    aureus before the onset of menstruation

11
Epidemiology
  • TSS associated with influenza or influenza-like
    illnesses mortality rate (43)
  • Nasal packing (nasal tampons) also associated
    with TSS

12
Pathophysiology
  • Most TSS associated with S. aureus
  • TSST-1 toxic shock syndrome toxin, exotoxin
  • Induce fever via the hypothalamus or via IL-1 and
    TNF
  • T-lymphocyte superantigenation and
    overstimulation
  • Induce interferon production
  • Enhance delayed hypersensitivity
  • Supress neutrophil migration and IG secretion
  • Enhance host suseptibility to exotoxins

13
Pathophysiology
  • Enterotoxins B and C
  • Similar chemical structure to TSST-1
  • Seen primarily in NMTSS
  • Elicit similar clinical manifestations as TSST-1

14
Pathophysiology
  • Vaginal conditions favorable to TSST-1
  • Temp 39-40 C
  • Neutral pH
  • PO2 gt 5
  • Supplemental CO2
  • Menstruation neutralizes vaginal pH
  • Tampon use may increase O2 and CO2
  • Synthetic fibers in tampon composition
  • Synergistic relationship between S. aureus and E.
    coli

15
Pathophysiology
  • Vasodilation rapid and massive onset
  • Hypotension
  • Decreased vasomotor tone, blood pooling,
    decreased vascular return
  • Nonhydrostatic leakage of fluid into the
    interstitium, contributing to hypotension and
    nonpitting edema of the head and neck
  • Depressed cardiac function
  • Total body water deficits from vomiting and
    diarrhea and fever

16
Pathophysiology
  • IL-1
  • Hypoalbuminemia, hypoferrinemia, and proteolysis
    manifest as peripheral edema, anemia, and
    rhabdomyolysis seen in TSS
  • TNF
  • Acidosis, shock, and multisystem organ failure
  • Multisystem organ failure
  • Direct result from toxin
  • Rapid onset of hypotension and decreased
    perfusion
  • Small amts of TSST-1 and enterotoxins B and C can
    be detected in pts with TSS up to 1 year

17
Clinical Features
  • TSS must be considered when
  • Unexplained febrile illness with erythroderma,
    hypotension, and diffuse organ pathology
  • Pts with NMTSS present 3rd to 5th days of menses
  • Postoperative NMTSS approx 2 days

18
Clinical Features
  • Mild TSS
  • Fever
  • Chills
  • myalgias
  • Abdominal pain
  • Sore throat
  • Nausea
  • Vomiting
  • Diarrhea
  • Self-limiting

19
Clinical Features
  • Severe
  • Acute onset
  • Early multiorgan envolvement
  • Prodrome
  • Headache, malaise, myalgias, nausea, vomiting,
    and diarrhea
  • Sudden onset of fevers and chills 1-4 days prior
    to presentation
  • Orthostatic lightheadedness, profuse watery
    diarrhea, sore throat, paresthesias, photophobia,
    abdominal pain, and cough

20
Clinical Presentation
  • PE
  • Hypotension
  • Pt appears acutely ill
  • Change in mental status
  • Oliguria
  • Nonpitting edema of face and extremities
  • Watery diarrhea
  • Pharygitis strawberry red tongue
  • Tender erythematous external genitalia diffuse
    vaginal hyperemia, strawberry cervix, scant
    purulent cervical discharge, bilat adenexal
    tenderness

21
Clinical Features
  • Rash diffuse painless blanching erythroderma,
    fades in three days
  • Followed by full-thickness desquamation
    particularly of palms and soles of feet
  • Severely affected patients may have hair and nail
    loss 2-3 months later

22
Clinical Features
  • Focal neuro findings are rare
  • Varying degrees of altered consciousness
  • Toxic encephalopathy - confusion, disorientation,
    agitation, hysteria, somnolence, and seizures
  • CT and LP will help deliniate

23
Clinical Features
  • Lab findings
  • Leukocytosis
  • lymphocytopenia
  • Anemia
  • ARF azotemia, myoglobinuria, sterile pyuria, RBC
    casts
  • Liver abnormalities
  • Metabolic acidosis 2nd to hypotension
  • Electrolyte abnormalities
  • Arrhythmias
  • ARDS

24
Differential Diagnosis
  • Acute pyelonephritis
  • Septic shock
  • Acute rheumatic fever
  • Scarlet fever strep or staph etiologies
  • Leigionares disease
  • PID
  • HUS

25
Differential Diagnosis
  • Acute viral syndrome
  • Leptospirosis
  • SLE
  • Rocky Mountain Spotted fever
  • Tick typhus
  • Gastroenteritis
  • Kawasaki disease
  • Reye syndrome
  • Toxic epidermal necrolysis
  • Erythema multiforme

26
Treatment
  • Aggressive shock management
  • Continuous monitoring central
  • Aggressive fluid replacement 4-20 L of
    crystalloid and FFP
  • Ventilatory management if ARDS develops
  • Complete blood work and cultures
  • Removal of foreign bodies, i.e. tampon or nasal
    packing
  • Antistaphlococcal penicillin or cephalosporin

27
Treatment
  • Antistaphlococcal penicillin or cephalosporin
  • Nafcillin or oxacillin 2g IV every 4hrs
  • Cefazolin 2g IV every 6hrs
  • Oral anti-staphlococcal ABx for the next 10 -14
    days

28
Treatment
  • Pt not treated with ß-lactamase-stable abx can
    have recurrence
  • MRTSS recurrence occurs in second month after
    the initial disease, recurring on the same day of
    the menstrual cycle
  • Initial episode is the most severe

29
Streptococcocal Toxic Shock Syndrome
  • Group A Strep
  • Soft tissue infection, early shock, multisystem
    organ failure, higher mortality than TSS, Flesh
    eating bacteria
  • Most serious Strep necrotizing fasciitis and
    myositis
  • STSS
  • Most commonly affects 20 50 yr olds without
    prior illness

30
STSS
  • Risk factors
  • Extremes of age
  • Diabetes
  • EtOH
  • Drug abuse
  • NSAIDS
  • Immunodeficiency
  • Rarely develops from symptomatic pharyngitis

31
STSS
  • 2000-3000 cases annually with 500 to 1500 cases
    of necrotizing fasciitis
  • Mortality rate of 30 80
  • 70 of cases progress to necrotizing fasciitis
  • Surgical intervention
  • Mortality
  • Strep fasciitis 60
  • Strep Myositis 85-100

32
Case Definition of Streptococcocal Toxic Shock
Syndrome
  • An illness with
  • Hypotension
  • Multiorgan involvement with two or more of the
    following
  • Renal impairment
  • Coagulopathy
  • Liver involvement
  • ARDS
  • Generalized erythematous macular rash that may
    desquamate
  • Soft tissue necrosis

33
Case Definition of Streptococcal Toxic Shock
Syndrome
  • Laboratory Criteria
  • Isolation of group A streptococcus
  • Case Classification
  • Probable clinical case definition in the
    absence of another identified etiology with
    isolation of group A strep from a nonsterile site
  • Confirmed clinical case definition with
    isolation of group A streptococcus from an
    otherwise sterile site

34
STSS
  • Epidemiology
  • Incidence 1-5 per 100,000
  • STSS associated Necrotizing Fasciitis 13-46
  • Pathophysiology
  • GAS invasive infections more virulent exotoxins
    than TSS
  • SPE Streptococcal pyogenic exotoxins
  • SPE A Scarlet fever toxin most potent and
    commonly isolated SPE in STSS cases
  • SPE A and B pyrogenicity, superactivation of
    T-cells, synthesis of TNF, IL-1 and IL-6, leading
    to acidosis, shock, organ failure

35
STSS
  • Patients without immunity to M-type SPE A and B
    producing strains of GAS are most susceptible to
    STSS
  • Portal of entry
  • Vagina, pharynx, mucosa, and skin, most are
    unidentifiable
  • Commonly begins at site of minor skin trauma

36
STSS
  • Clinical Features
  • Pain most common with preceding local tenderness
  • May present as
  • Peritonitis
  • PID
  • Pneumonia
  • Pericarditis
  • Fever
  • Severe pain
  • Swelling
  • Redness
  • Compartment syndrome

37
STSS
  • PE
  • Fever
  • Shock on admission or within 4-8hrs
  • Vesicles and/or bullae at infection site
  • ARDS
  • Less commonly erythematous rash
  • Labs
  • Mild increase in WBC
  • LFT 2x normal

38
STSS
  • Labs
  • Decreased platelets
  • Disseminated intravascular coagulopathy
  • Renal dysfunction requiring dyalysis
  • Blood cultures - GAS 60
  • Tissue cultures 90

39
STSS
  • Diagnosis
  • Differential is the same as for TSS with the
    addition of invasive and noninvasive GAS
    infections, necrotizing fasciitis, myositis,
    serious infections caused by C. perforingens and
    C. septicum, and mixed aneorbic and aerobic
    organisms
  • Treatment
  • Aggressive shock management with early use of
    vasopressors

40
STSS
  • IV ABx should be started in the ED once cultures
    have been taken. Inability to obtain Cx should
    not delay administration of IV ABx
  • Pen G 24 million U/d divided
  • Clindamycin 900mg IV q 8hr
  • Erythromycin 1g IV q 6 hr in PCN allergic pts
  • Ceftriaxone 2g IV q 24 hr with Clindamycin 900mg
    IV q 8hr
  • IVIG 2g/kg q 48 hr in patients without IGA
    deficiency improve 30 day mortality

41
STSS
  • Surgery
  • Prompt consultation in addition to IV ABx
  • Exploration
  • Debridement
  • 70 of cases require debridement, fasciotomy, or
    amputation

42
TSS and STSS
  • 1.) Toxic Shock Syndrome is only a disease of
    young healthy menstruating women. T/F
  • 2.) The rash of TSS is a diffuse, blanching,
    erythroderma, classically described as a
    painless sunburn, that fades within 3-4 days of
    its appearance and is followed by full-thickness
    desquamation of the palms and soles during
    convalescence. T/F

43
TSS and STSS
  • 3.) STSS is defined as any group A
    streptococcocal (GAS) infection with invasive
    soft tissue infection, early onset of shock, and
    organ failure. T/F
  • 4.) STSS associated with GAS invasive infections
    most commonly affects individual between the ages
    of 20 50 with a predisposing illness. T/F
  • Answers 1.) F, 2.) T, 3.) T, 4.) F

44
TSS and STSS
  • Tintinalli et al Emergency Medicine A
    Comprehensive Study Guide. Chap. 142, pg.
    913-918.
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