Toxic shock syndrome (TSS) is a condition which may be caused by either Staphylococcus aureus 1 or Streptococcus pyogenes (group A streptococci) 2 – the latter is described in the article on GAS infections
TSS is characterized by rapid onset of high fever, vomiting, watery diarrhea, sore throat, myalgia and headache in a previously healthy person
The disease was first described in 1978 and was known in wider circles in 1980 during a number of disease cases in younger women assicieret with tampon use by menstruation;hence the name tamponsyge
occurrence
Incidence and prevalence
The condition is rare
The incidence has decreased considerably since the first cases – primarily because of the information and changes in the way tampons are manufactured in
Age
Initially so that up to 90% of cases in women of childbearing age and most often among young women
Clinical disease occurred during the menstrual period and were associated with the use of highly absorbent tampons
TSS related to menstruation
Originally, so that an incidence of between 6 and 12 per. 100,000 persons, but with changes in the method of production fell to about this 1 case per. 100000
It seems in recent years to be a slight increase in incidence – mainly because cases are not associated with tampon use, is slightly increasing
Recent estimates indicate an incidence of approximately 3 per. 100,000 people
Etiology and pathogenesis
etiology
The syndrome can occur in all patients with a focus of toxin yellow staphylococci
Previously, the condition most common in menstruating women who had had tampon lying too long
However, staphylococci from the nasopharynx, vagina, rectum and wounds all been associated with the condition
TSS are often caused by toxic shock syndrome toxin (TSST-1)
Situations not related to menstruation, is often caused by strains that do not produce TSST-1
Staphylococcal enterotoxin B, or C 1 may also mediate mode
staphylococci
Staphylococcus aureus is an aerobic, Gram-positive bacterium
Causes different infections from folliculitis and hudabcesser to bacteremia and endocarditis
The bacterium colonizes the skin and mucous membranes in 30-50% of healthy adults and children, mostly in the front part of the nose, skin, vagina and rectum
S. aureus can multiply in the tissues and produce a number of enzymes which induce inflammation and abscesses
Many strains produce exotoxins that leads to three other syndromes:
food poisoning – caused by intake of S. aureus enterotoxin
“Scalded skin syndrome” – caused by an exfoliative toxin
TSS – caused by toxic shock syndrome toxin-1 (TSST-1) and other enterotoxins
Exotoxins cause disease because they are super antigens; that is molecules that activate large amounts of T cells – up to 20% of all T cells at the same time, resulting in a massive cytokine production
Pathogenesis of TSS
The pathogenesis involves the establishment of a toxin producing bacterial strain in a non-immunized subject, under conditions which favor the growth of bacteria, for example. an aerobic environment rich in nutrients
The host’s antibody response to S. aureus exotoxins play an important role in the pathogenesis
70-80% of all individuals develop antibodies to TSST-1 during the teenage years and by 40 years of age have 90-95% such antibodies
Patients with clinically TSS lack antibodies to TSST-1 and also appears to have reduced ability to generate such antibodies
ICPC 2
A78 Infectious disease IKA
ICD-10
A483 Toxic shock syndrome
Diagnosis
diagnostic criteria
Fever of 38.9 ° C
Diffuse macular rash erythematous, flaking of the palms and soles during the two weeks
hypotension
Involvement of three or more bodies
The gastrointestinal tract (vomiting, diarrhea)
Kidney or liver failure
Hyperaemia of the mucous membranes (non-purulent conjunctivitis)
thrombocytopenia
Myalgia with elevated CK
Confusion with normal spinal fluid
hypocalcemia
Differential
meningococcemia
Scarlet fever (Group A streptococci)
Toxic epidermal necrolysis
Kawasaki’s syndrome
Rocky Mountain spotted fever
Medical history
The symptomatology may vary due to the effect of S. aureus -toksinet, but there is no difference in principle in the menstrual and non-menstrual-related disease
The condition usually starts acutely in a previously healthy young woman who has used tampons
In many symptoms start within several days after the start of menstruation in a woman who has used tampon, or after surgery; exceptionally symptoms may occur later
There are high fever, vomiting and watery diarrhea
Sore throat, myalgia and headache are frequent
clinical findings
All patients with safe TSS fever> 38.9 ° C, hypotension and skin manifestations
Diffuse macular rash erythematous
Non-purulent conjunctivitis
hyperemic vaginal mucosa
In severe cases there hypotension with kidney and heart failure
hypotension
Defined as systolic blood pressure less than 90 mmHg and orthostatic reduction in diastolic pressure of 15 mm Hg or orthostatic dizziness or syncope
Occurs rapidly and can lead to ischemia and organ failure as kidney and heart failure
Hypotension due to decreased systemic vascular resistance, as well as non-leakage of hydrostatic fluid from intravaskulærrummet to the interstitial space, both mechanisms is due to the massive release of cytokines induced by toxins
Skin manifestations
Various skin manifestations can be seen by TSS
The initial erythroderma involving both skin and mucous membranes and is characterized by a diffuse red, macular rash, which is reminiscent of suntanning, but which also includes the palms and soles
Slimhindeaffektionen include conjunctival hemorrhage and hyperemia of the lining of the vagina and mouth / throat
The patient will also have edema
Sensymptomer may be a maculopapular rash itching that may occur one to two weeks after initiation of the disease, and peeling of the soles of the feet, and palms of the hands typically occurs 1-3 weeks after disease onset
Some patients experience loss of hair and nails 1-2 months later
Multi-organ involvement
TSS can affect all body systems
Many patients complain of diffuse myalgias and muscle weakness
Gastrointestinal symptoms are frequent, particularly acute diarrhea
Both prerenal, renal and renal failure may occur and results in metabolic disorders
Encephalopathy can manifest as disorientation, confusion and convulsions, and is probably due to cerebral edema
Persistent neuropsychological genes can develop – such as headache, loss of memory and poor concentration
additional studies
Detection of S. aureus is not necessary to make the diagnosis
Yellow staphylococci can be cultured from vaginal discharge or ulcers
Blood culture is usually negative (95%)
When to refer the patient?
On suspicion of TSS
Treatment
Treatment goals
Survival
Generally about the treatment
Correcting shock
Correcting kidney and lung failure and disseminated intravascular coagulation
antibiotics intravenously
Drainage of focal accumulations of yellow staphylococci
Medical treatment
infection Treatment
antibiotics intravenously
Probably antibiotics such as clindamycin , which suppresses protein synthesis more efficient than cell wall-active substances such as beta-lactam antibiotics
On the empirical basis is often recommended a combination of clindamycin and dicloxacillin
Duration of treatment is 1-2 weeks
immunoglobulin
This will probably be used in most places
corticosteroids
There is no evidence for the use of steroid
shock Treatment
fluid therapy
Significant fluid replacement may be required for several days
pressor
May be necessary
other treatment
Search foreign
Surgery
Drainage of any foci
At postoperative patients seeing surgical wounds often do not appear to be infected due to decreased inflammatory response, but the wound should still Exploration, if the patient meets the criteria for TSS
preventive treatment
When using tampons
Must be changed regularly; tampons should be no more than 12 hours
Check that all the tampons are removed
Course, complications and prognosis
Progress
Initially, up to 30% of menstruating women with TSS relapses
Recidiverne is usually milder
complications
Kidney and heart failure
shock
ARDS (adult respiratory distress syndrome)
Disseminated intravascular coagulation (DIC)
Forecast
Mortality appears to be greater for non-tamponassocieret TSS; A recent French study, mortality was 0 in women with tamponassocieret TSS 3
