Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

Makindo Medical Notes "One small step for man, one large step for Makindo"
Download all this content in the Apps now Android App and Apple iPhone/Pad App

MEDICAL DISCLAIMER: The contents are under continuing development and improvements and despite all efforts may contain errors of omission or fact. This is not to be used for the assessment, diagnosis, or management of patients. It should not be regarded as medical advice by healthcare workers or laypeople. It is for educational purposes only. Please adhere to your local protocols. Use the BNF for drug information. If you are unwell please seek urgent healthcare advice. If you do not accept this then please do not use the website. Makindo Ltd.

Toxic Shock Syndrome

About

Anaesthetics and Critical Care

Obstetrics Gynaecology

Oncology

Ophthalmology

Oral Medicine and Dentistry

Statistics and Research

Stroke

Surgery

Toxicology

Trauma and Orthopaedics

Twitter

Urology

⚠️ Toxic Shock Syndrome (TSS) is a life-threatening emergency 🆘. Patients can deteriorate within hours. Often triggered by 🩸 tampon use, 🤕 minor wounds, or 🏥 surgical packing. 💉 Early aggressive fluids + broad-spectrum antibiotics = survival. Look for 🚨 rash, diarrhoea, hypotension, altered mental status.

🚑 Initial Shock Management
🫁 ABC approach: Secure airway, support breathing, restore circulation. 💉 IV Access: 2 large-bore cannulas → give 20 mL/kg crystalloid bolus, repeat as needed. 💊 Antibiotics (STAT): IV clindamycin + vancomycin ± piperacillin–tazobactam (or meropenem if very unwell). 🩸 Remove source: Tampon, nasal packing, surgical drains, or debride necrotic tissue. 📊 Investigations: FBC, U&E, LFTs, clotting, lactate, troponin, D-dimer, ABG, group & save. 🚽 Catheterise: Strict fluid balance → urine output target ≥0.5 mL/kg/hr. 🔥 Severity markers: High fever, rash, shock, lactate >2 mmol/L. 🧪 IVIG: Consider in severe/refractory cases to neutralise toxins. 🏥 ICU referral: Vasopressors (noradrenaline) if fluids fail.

🚑 Initial Shock Management

🫁 ABC approach: Secure airway, support breathing, restore circulation.
💉 IV Access: 2 large-bore cannulas → give 20 mL/kg crystalloid bolus, repeat as needed.
💊 Antibiotics (STAT): IV clindamycin + vancomycin ± piperacillin–tazobactam (or meropenem if very unwell).
🩸 Remove source: Tampon, nasal packing, surgical drains, or debride necrotic tissue.
📊 Investigations: FBC, U&E, LFTs, clotting, lactate, troponin, D-dimer, ABG, group & save.
🚽 Catheterise: Strict fluid balance → urine output target ≥0.5 mL/kg/hr.
🔥 Severity markers: High fever, rash, shock, lactate >2 mmol/L.
🧪 IVIG: Consider in severe/refractory cases to neutralise toxins.
🏥 ICU referral: Vasopressors (noradrenaline) if fluids fail.

📖 About TSS

🧬 Superantigen-mediated → massive cytokine storm 🌊 → capillary leak + shock.
⏱️ Rapid onset → multi-organ failure if untreated.
🔗 Classic tampon link, but also wounds, burns, nasal packs, surgery.
📉 Mortality: ~2–5% with treatment; up to 30% if delayed or streptococcal.

🌍 Epidemiology

Rare: ~1–3 cases / 100,000 per year.
🧑‍🦰 Classically menstruating women (tampons), but also 👶 children, 👨 men, 👵 elderly.
🟡 Staphylococcal TSS = more common; 🔴 Streptococcal TSS = more severe ⚡ (often with necrotising fasciitis).

🦠 Aetiology & Pathophysiology

Pathogen	Mechanism
🟡 Staph aureus	TSST-1 + enterotoxins → T-cell hyperactivation → cytokine storm → shock & MODS.
🔴 Group A Strep	SPE exotoxins → fulminant disease, necrotising fasciitis, ↑ mortality.
⚪ Other bacteria	Mixed surgical / postpartum infections with superantigen production.

⚠️ Risk Groups

🩸 Tampon use (esp. high absorbency, prolonged use).
🤕 Wounds, burns, skin infections.
🏥 Postoperative patients with retained packing.
🧒 Children post-varicella (risk of invasive Strep A).
🛡️ Immunocompromised or chronic illness.

📋 Case Definition (CDC)

Criterion	Description
🌡️ Fever	≥38.9°C
🌺 Rash	Diffuse erythematous rash → desquamation (palms/soles) 1–2 weeks later
⬇️ Hypotension	SBP ≤90 mmHg or age-adjusted
🧍 Multiorgan	≥3 systems affected (GI, mucosa, renal, hepatic, muscular, CNS, platelets)
🚫 Exclusion	No alternative explanation
🧫 Micro	S. aureus or Strep pyogenes isolation (not always positive)

🛠️ Management by Cause

Cause	Description	Management
🟡 Staph aureus	Menstrual or wound-related	Remove source 🔎 IV fluids 💧 Clindamycin + vancomycin 💊 ± IVIG in severe cases 🧪 ICU monitoring 🏥
🔴 Strep pyogenes	Often with necrotising fasciitis	Urgent surgical debridement ✂️ Penicillin + clindamycin 💊 IV fluids & vasopressors 💧 Consider IVIG 🧪 ICU monitoring 🏥
⚪ Other causes	Mixed / postoperative	Source control 🧼 Targeted antibiotics 🎯 Supportive haemodynamic care 💉 ICU support 🏥

📝 Exam Pearls

Clindamycin = key (blocks toxin production) 💊.
Rash + hypotension + multiorgan = think TSS 🚨.
Remove tampon/packing FIRST before anything else 🔎.
Strep TSS → always look for necrotising fasciitis 🦵.

🛡️ Prevention

🩸 Change tampons every 4–6h; alternate with pads at night.
🚫 Avoid very high absorbency tampons unless needed.
🧼 Strict wound care; remove packing promptly.
📢 Education for patients on early red flag symptoms.

📚 References

Paediatric TSS Guideline (NHS)
TSS Information Resource
Fisher MC, et al. JAMA 2019;321(6):588-598.

🧑‍⚕️ Case Examples — Toxic Shock Syndrome (TSS)

Case 1 (Menstrual-related TSS): 🩸 A 23-year-old woman presents with sudden high fever, vomiting, diarrhoea, and diffuse erythematous rash. She is hypotensive (BP 80/50), tachycardic, and confused. She has been using a high-absorbency tampon for >24 hours. Analysis: Classic menstrual-related TSS due to Staphylococcus aureus toxin release. Diagnosis: Clinical — fever, hypotension, rash, multi-organ involvement. Management: Immediate resuscitation with IV fluids, remove tampon, IV clindamycin + flucloxacillin, ICU support if shock persists. IVIG in refractory cases.
Case 2 (Post-surgical TSS): 🏥 A 45-year-old man develops fever, diffuse rash, hypotension, and acute renal failure 5 days after orthopaedic surgery. Wound looks relatively clean. Analysis: Non-menstrual TSS, typically due to Staphylococcus aureus or Streptococcus pyogenes. Local infection may look mild, but systemic toxin effect is profound. Diagnosis: Sepsis with shock + rash + multiorgan involvement in a post-surgical patient. Management: Broad-spectrum IV antibiotics (including clindamycin to inhibit toxin production), surgical wound review/debridement, aggressive fluid resuscitation, vasopressors if refractory.
Case 3 (Streptococcal TSS with necrotising fasciitis): ⚠️ A 36-year-old woman presents with severe leg pain, fever, hypotension, and rapidly spreading erythema after a minor cut while gardening. Exam shows swelling, blistering, and crepitus. Analysis: Streptococcal TSS complicating necrotising fasciitis. Toxin-mediated vasodilation and cytokine storm cause shock and multi-organ failure. Diagnosis: Fulminant soft-tissue infection with systemic shock and rash. Management: Emergency surgical debridement, IV clindamycin + carbapenem, IV fluids, vasopressors, ICU care. Consider IVIG.

Download Makindo Medical Students on the App Store

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

Edit