Toxic shock syndrome diagnostic criteria: Difference between revisions

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Latest revision as of 00:26, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

Diagnosis of Toxic Shock Syndrome (TSS) is mainly based on the clinical presentation including fever >38.9°C, hypotension, diffuse erythroderma, desquamation.

Diagnostic Criteria

Toxic Shock Syndrome (Other Than Streptococcal) (TSS)

Clinical Criteria

The diagnosis of Staphylococcal toxic shock syndrome (TSS) is based upon clinical presentation. An epidemiological clinical criteria list has been established by United States Centers for Disease Control and Prevention (CDC) for epidemiologic studies on Staphylococcal TSS. This criteria list is epidemiologicaly usable only, meaning that a patient can not be excluded from disease based on the absence of one of these criteria. This criteria list points that a confirmed case is someone who has fever >38.9°C, hypotension, diffuse erythroderma, desquamation (unless the patient dies before desquamation can occur), and involvement of at least three organ systems. If a patient misses one of these criteria, the case may be considered as a probable/susceptible case.^[1]

TSS diagnosis can be made with the following clinical manifestations:

Fever: Temperature greater than or equal to 102.0°F (greater than or equal to 38.9°C)
Rash: Diffuse macular erythroderma
Desquamation: 1-2 weeks after onset of rash
Hypotension: Systolic blood pressure less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years
Multiorgan involvement (three or more of the following organ systems):
- Gastrointestinal:
  - Vomiting
  - Diarrhea at onset of illness (especially watery)
- Muscular:
  - Severe myalgia
  - Increased creatine phosphokinase (CPK) level at least twice the upper limit of normal
- Mucous membrane inflammation:
- Renal:
  - Blood urea nitrogen or creatinine at least twice the upper limit of normal.
  - Urinary sediment with pyuria (greater than or equal to 5 leukocytes per high-power field) in the absence of urinary tract infection
- Hepatic: Increase of the hepatic enzymes twice the upper limit of normal.
- Hematologic:
  - Platelets less than 100,000/mm3
- Central nervous system:
  - Disorientation or alterations in consciousness without focal neurologic signs.^[2]^[3]

Laboratory Criteria for Diagnosis

If the result of the following tests become negative, it can be considered a positive criteria for TSS:

Blood culture: Blood culture may be positive for Staphylococcus aureus.
Cerebrospinal fluid cultures
Negative serologies for:

Streptococcal TSS

There is a subtle difference between Streptococcal TSS and other types. Group A Streptococcus(GAS) can be isolated in GAS-related TSS patients.

Clinical and biochemical criteria of streptococcal TSS and necrotizing fasciitis (NF).^[5]

Disease Presentation	Criteria		Definite case	Suspected case
Streptococal TSS	A. Isolation of group A Streptococcus	1. From a sterile site 2. From a nonsterile body site	A1 + B(complete)	A2 + B(complete)
Streptococal TSS	B. Clinical signs of severity	Hypotension Clinical and laboratory abnormalities (requires two or more of the following): Renal Failure Coagulopathy Hepatic failure Acute respiratory distress syndrome (ARDS) Extensive tissue necrosis i.e. necrotizing fasciitis Erythematous rash	A1 + B(complete)	A2 + B(complete)
Necrotizing fasciitis	A. Clinical Criteria	Necrosis of soft tissues with involvement of the fascia Serious systemic disease, including one or more of the following: Shock Systolic blood pressure <90 mm of Hg Disseminated intravascular coagulopathy Failure of organ systems Respiratory failure Liver failure Renal failure	A (complete) + B1	A (complete) + B2 A(complete) + B3
Necrotizing fasciitis	B. Isolation of group A Streptococcus	Isolation of group A Streptococcus from a normally sterile body sites Serologic confirmation of group A streptococcal infection by a 4-fold rise against: a) streptolysin O b) DNase B 3. Histologic confirmation: Gram-positive cocci in a necrotic soft tissue infection	A (complete) + B1	A (complete) + B2 A(complete) + B3

References

↑ Tofte RW, Williams DN (1981). "Toxic shock syndrome. Evidence of a broad clinical spectrum". JAMA. 246 (19): 2163–7. PMID 7289007.
↑ cite journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}
↑ "Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention". MMWR Recomm Rep. 46 (RR-10): 1–55. 1997. PMID 9148133.
↑ "Toxic Shock Syndrome (Other Than Streptococcal) | 2011 Case Definition".
↑ "wwwnc.cdc.gov" (PDF).

Template:WikiDoc Sources

[pmid7289007-1] Tofte RW, Williams DN (1981). "Toxic shock syndrome. Evidence of a broad clinical spectrum". JAMA. 246 (19): 2163–7. PMID 7289007.

[pmid2294395-2] te journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}

[pmid9148133-3] "Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention". MMWR Recomm Rep. 46 (RR-10): 1–55. 1997. PMID 9148133.

[urlToxic_Shock_Syndrome_(Other_Than_Streptococcal)_|_2011_Case_Definition-4] "Toxic Shock Syndrome (Other Than Streptococcal) | 2011 Case Definition".

[urlwwwnc.cdc.gov-5] "wwwnc.cdc.gov" (PDF).

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[3]

[4]

[5]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Toxic shock syndrome}}
-Please help WikiDoc by adding more content here.  It's easy!  Click  [[Help:How_to_Edit_a_Page|here]]  to learn about editing.
+{{CMG}},{{AE}}{{MIR}}
-{{CMG}},{{MIR}}
+== Overview ==
+Diagnosis of [[Toxic shock syndrome|Toxic Shock Syndrome]] (TSS) is mainly based on the clinical presentation including [[fever]] >38.9°C, [[hypotension]], diffuse [[erythroderma]], [[desquamation]].
+==Diagnostic Criteria==
+=== Toxic Shock Syndrome (Other Than Streptococcal) (TSS) ===
+==== Clinical Criteria ====
+The diagnosis of [[Staphylococcus|Staphylococcal]] [[toxic shock syndrome]] (TSS) is based upon clinical presentation. An epidemiological clinical criteria list has been established by United States Centers for Disease Control and Prevention ([[Centers for Disease Control and Prevention|CDC]]) for [[Epidemiology|epidemiologic]] studies on [[Staphylococcus|Staphylococcal]] TSS. This criteria list is epidemiologicaly usable only, meaning that a patient can not be excluded from disease based on the absence of one of these criteria. This [[criteria]] list points that a confirmed case is someone who has [[fever]] >38.9°C, [[hypotension]], diffuse [[erythroderma]], [[desquamation]] (unless the patient dies before [[desquamation]] can occur), and involvement of at least three organ systems. If a patient misses one of these criteria, the case may be considered as a probable/susceptible case.<ref name="pmid7289007">{{cite journal |vauthors=Tofte RW, Williams DN |title=Toxic shock syndrome. Evidence of a broad clinical spectrum |journal=JAMA |volume=246 |issue=19 |pages=2163–7 |year=1981 |pmid=7289007 |doi= |url=}}</ref>
-== Overview ==
+[[Toxic shock syndrome|TSS]] diagnosis can be made with the following clinical manifestations:
-The diagnostic criteria varies depend on the organism responsible for the Toxic Shock Syndrome (TSS), but mainly the diagnosis of TSS is based on the clinical presentation.
+* [[Fever]]: [[Temperature]] greater than or equal to 102.0°F (greater than or equal to 38.9°C)
+* [[Rash]]: Diffuse [[macular]] [[erythroderma]]
+* [[Desquamation]]: 1-2 weeks after onset of rash
+* [[Hypotension]]: [[Systolic blood pressure]] less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years
+* [[Multiorgan failure|Multiorgan involvement]] (three or more of the following organ systems):
+** [[Gastrointestinal]]:
+*** [[Vomiting]]
+*** [[Diarrhea]] at onset of [[illness]] (especially watery)
+** [[Muscular]]:
+*** Severe [[myalgia]]
+*** Increased [[creatine phosphokinase]] ([[CPK]]) level at least twice the upper limit of normal
+** [[Mucous membrane]] [[Conjunctival disease|inflammation]]:
+***[[Vaginal]]
+***[[Oropharyngeal]]
+***[[Conjunctival disease|Conjunctival]]
+** [[Kidney|Renal]]:
+*** [[Blood urea nitrogen]] or [[creatinine]] at least twice the upper limit of normal.
+*** Urinary sediment with [[pyuria]] (greater than or equal to 5 [[leukocytes]] per high-power field) in the absence of [[urinary tract infection]]
+** [[Hepatic]]: Increase of the hepatic enzymes twice the upper limit of normal.
+*** [[Bilirubin|Total bilirubin]]
+*** [[Alanine aminotransferase|Alanine]] [[aminotransferase]]
+*** [[Aspartate|Aspartate aminotransferase]]
+** [[Hematologic]]:
+*** [[Platelets]] less than 100,000/mm3
+** [[Central nervous system]]:
+*** [[Disorientation]] or alterations in [[consciousness]] without [[focal neurologic signs]].<ref name="pmid2294395"><nowiki>cite journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}</nowiki></ref><ref name="pmid9148133">{{cite journal |vauthors= |title=Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention |journal=MMWR Recomm Rep |volume=46 |issue=RR-10 |pages=1–55 |year=1997 |pmid=9148133 |doi= |url=}}</ref>
-==Diagnostic Criteria==
+==== Laboratory Criteria for Diagnosis ====
-=== Staphylococcal toxic shock syndrome (TSS) ===
+If the result of the following tests become negative, it can be considered a positive criteria for TSS:
-**
+* [[Blood]] culture: Blood culture may be positive for [[Staphylococcus aureus]].
+* C[[cerebrospinal fluid|erebrospinal fluid]] cultures
+* Negative [[Serology|serologies]] for:
+** [[Rocky Mountain spotted fever|Rocky Mountain Spotted Fever]]
+** [[Leptospirosis]]
+** [[Measles]]<ref name="urlToxic Shock Syndrome (Other Than Streptococcal) | 2011 Case Definition">{{cite web |url=https://wwwn.cdc.gov/nndss/conditions/toxic-shock-syndrome-other-than-streptococcal/case-definition/2011/ |title=Toxic Shock Syndrome (Other Than Streptococcal) &#124; 2011 Case Definition |format= |work= |accessdate=}}</ref>
-= Toxic Shock Syndrome (Other Than Streptococcal) (TSS) =
+=== Streptococcal TSS ===
+There is a subtle difference between [[Streptococcus|Streptococcal]] TSS and other types. [[Streptococcus|Group A Streptococcus(GAS]]) can be isolated in GAS-related TSS patients.
+====Clinical and biochemical criteria of [[Streptococcus|streptococcal]] TSS and [[necrotizing fasciitis]] (NF).<ref name="urlwwwnc.cdc.gov">{{cite web |url=https://wwwnc.cdc.gov/eid/article/1/3/pdfs/95-0301.pdf |title=wwwnc.cdc.gov |format= |work= |accessdate=}}</ref>====
+{| class="wikitable"
+! align="center" style="background:#4479BA; color: #FFFFFF;" |Disease Presentation
+! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Criteria
+! align="center" style="background:#4479BA; color: #FFFFFF;" |Definite case
+! align="center" style="background:#4479BA; color: #FFFFFF;" |Suspected case
+|-
+! rowspan="2" align="center" style="background:#DCDCDC;"|Streptococal TSS
+|A. Isolation of group A [[Streptococcus]]
+|1. From a [[sterile]] site
-=== Clinical Criteria ===
+. From a nonsterile body site
-The diagnosis of Staphylococcal toxic shock syndrome (TSS) is based upon clinical presentation as no confirmatory diagnostic criteria is developed yet. A criteria list have been established by United States Centers for Disease Control and Prevention ([[Centers for Disease Control and Prevention|CDC]]) for epidemiologic studies on Staphylococcal TSS, mean that a patient can not be excluded from disease based on the absence of one of these criterias when it come to diagnosis terms. This criteria list means that a confirmed case is someone who has fever >38.9°C, [[hypotension]], diffuse [[erythroderma]], [[desquamation]] (unless the patient dies before desquamation can occur), and involvement of at least three organ systems. If a patient misses one of these criterias, the case may be considered as a probable case.<ref name="pmid7289007">{{cite journal |vauthors=Tofte RW, Williams DN |title=Toxic shock syndrome. Evidence of a broad clinical spectrum |journal=JAMA |volume=246 |issue=19 |pages=2163–7 |year=1981 |pmid=7289007 |doi= |url=}}</ref>
+| rowspan="2" |A1 '''+''' B(complete)
-An illness with the following clinical manifestations:
+| rowspan="2" |A2 '''+''' B(complete)
-* Fever: temperature greater than or equal to 102.0°F (greater than or equal to 38.9°C)
-* Rash: diffuse macular erythroderma
-* Desquamation: 1-2 weeks after onset of rash
-* Hypotension: systolic blood pressure less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years
-* Multisystem involvement (three or more of the following organ systems):
-** Gastrointestinal: vomiting or diarrhea at onset of illness
-** Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal
-** Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia
-** 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 high-power 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/mm3
-** Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent<ref name="pmid2294395"><nowiki>cite journal |vauthors= |title=Repeat injuries in an inner city population--Philadelphia, 1987-1988 |journal=MMWR Morb. Mortal. Wkly. Rep. |volume=39 |issue=1 |pages=1–3 |year=1990 |pmid=2294395 |doi= |url=}}</nowiki></ref><ref name="pmid9148133">{{cite journal |vauthors= |title=Case definitions for infectious conditions under public health surveillance. Centers for Disease Control and Prevention |journal=MMWR Recomm Rep |volume=46 |issue=RR-10 |pages=1–55 |year=1997 |pmid=9148133 |doi= |url=}}</ref>.
-=== Laboratory Criteria for Diagnosis ===
+|-
-Negative results on the following tests, if obtained:
+|B. Clinical signs of severity
-* Blood or cerebrospinal fluid cultures blood culture may be positive for ''Staphylococcus aureus'')
+|
-* Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles
+* [[Hypotension]]
+* Clinical and laboratory abnormalities (requires two or more of the following):
+** [[Renal Failure]]
+** [[Coagulopathy]]
+** [[Hepatic failure]]
+** [[Acute respiratory distress syndrome]] (ARDS)
+** Extensive tissue [[necrosis]] i.e. necrotizing fasciitis
+** [[Erythematous]] [[rash]]
+|-
+! rowspan="2" align="center" style="background:#DCDCDC;"|Necrotizing fasciitis
+|A. Clinical Criteria
+|
+* [[Necrosis]] of [[Soft tissue|soft tissues]] with involvement of the [[fascia]]
-=== Case Classification ===
+* Serious systemic disease, including one or more of the following:
+** [[Shock]]
+** [[Systolic blood pressure]] <90 mm of Hg
+** [[Disseminated intravascular coagulopathy]]
+** Failure of organ systems
+*** [[Respiratory failure]]
+*** [[Hepatic failure|Liver failure]]
+*** [[Renal failure]]
+| rowspan="2" |A (complete) '''+''' B1
-==== Probable ====
+| rowspan="2" |A (complete) '''+''' B2
-A case which meets the laboratory criteria and in which four of the five clinical criteria described above are present
+A(complete) '''+''' B3
-==== Confirmed ====
+|-
-A case which meets the laboratory criteria and in which all five of the clinical criteria described above are present, including desquamation, unless the patient dies before desquamation occurs
+|B. Isolation of group A [[Streptococcus]]
+|
+# Isolation of group A [[Streptococcus]] from a normally [[sterile]] body sites
+# [[Serological testing|Serologic]] confirmation of group A [[Streptococcus|streptococcal]] infection by a 4-fold rise against:
+::a) streptolysin O b) [[DNase|DNase B]]
+:3. [[Histologic]] confirmation: [[Gram-positive cocci]] in a [[Necrotic tissue|necrotic soft tissue infection]]
+|}
 ==References==
@@ Line 52: / Line 113: @@
 [[Category:Disease]]
 [[Category:Syndromes]]
-[[Category:Infectious disease]]
 [[Category:Needs overview]]
 [[Category:Needs content]]
+[[Category:Emergency mdicine]]
+[[Category:Up-To-Date]]
+[[Category:Infectious disease]]