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).

[1]

[2]

[3]

[4]

[5]

@@ Line 4: / Line 4: @@
 == Overview ==
-Diagnosis of [[Toxic shock syndrome|Toxic Shock Syndrome]] (TSS) is mainly based on the clinical presentation.
+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]].
-==Overview:==
-Although the best [[Diagnosis|diagnostic]] tool for [[toxic shock syndrome]] (TSS) [[diagnosis]] is with clinical findings and laboratory exams, there are still some imaging and specific diagnostic ways specially for early diagnosis of TSS complications.
-==Imaging==
-Different imaging methods during [[toxic shock syndrome]] (TSS) evaluation are more useful to assess the disease [[complications]], and for early [[diagnosis]] and treatment of complications.
-===CXR===
-[[Diffuse]] [[bilateral]] [[interstitial]] and alveolar infiltrates may be seen in [[Chest X-ray|CXR]] (as a result of [[pulmonary]] and cardiac complications).
-===Brain CT-scan===
-Midline shift, or [[effacement]] of the [[basilar]] cisterns may be seen due to [[cerebral edema]]. Some experts insist in the usefulness of [[magnetic resonance imaging]] because of its [[Sensitivity (tests)|sensitivity]], although the imaging technique lacks [[Specificity (tests)|specificity]] in the diagnosis of TSS related complications.<ref name="pmid21406630">{{cite journal |vauthors=Kim KT, Kim YJ, Won Lee J, Kim YJ, Park SW, Lim MK, Suh CH |title=Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging? |journal=Radiology |volume=259 |issue=3 |pages=816–24 |year=2011 |pmid=21406630 |doi=10.1148/radiol.11101164 |url=}}</ref><ref name="pmid23043899">{{cite journal |vauthors=Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC |title=Necrotizing fasciitis: contribution and limitations of diagnostic imaging |journal=Joint Bone Spine |volume=80 |issue=2 |pages=146–54 |year=2013 |pmid=23043899 |doi=10.1016/j.jbspin.2012.08.009 |url=}}</ref>
-==Frozen-section biopsy==
-Early recognition of [[necrotizing fasciitis]] (NF) can be made by using of specimens of suspected areas of tissue ; however, it requires high expertise to process and interpret [[biopsy]] specimens, which is not readily available in most clinical settings where and when patients present<ref name="pmid6727947">{{cite journal |vauthors=Stamenkovic I, Lew PD |title=Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy |journal=N. Engl. J. Med. |volume=310 |issue=26 |pages=1689–93 |year=1984 |pmid=6727947 |doi=10.1056/NEJM198406283102601 |url=}}</ref>.
-==Staphylococcus aureus antibody testing==
-Presence of [[Staphylococcus]] [[Staphylococcus aureus|aureus]] in the absence of an acute-phase [[antibody]] can be highly suggestive of [[Staphylococcus|Staphylococcal]] TSS.
 ==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 as no confirmatory diagnostic criteria is developed yet. An epidemiological clinical criteria list have 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, 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/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>
+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>
-TSS [[illness]] diagnosis can be mad with the following clinical manifestations:
+[[Toxic shock syndrome|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]]
@@ Line 32: / Line 19: @@
 ** [[Gastrointestinal]]:
 *** [[Vomiting]]
-*** [[diarrhea]] at onset of [[illness]] (especially watery)
+*** [[Diarrhea]] at onset of [[illness]] (especially watery)
 ** [[Muscular]]:
-*** Severe myalgia
+*** Severe [[myalgia]]
-*** Increase creatine phosphokinase (CPK) level at least twice the upper limit of normal
+*** Increased [[creatine phosphokinase]] ([[CPK]]) level at least twice the upper limit of normal
-** [[Mucous membrane]]:
+** [[Mucous membrane]] [[Conjunctival disease|inflammation]]:
 ***[[Vaginal]]
 ***[[Oropharyngeal]]
-***[[Conjunctival disease|Conjunctival hyperemia]]
+***[[Conjunctival disease|Conjunctival]]
 ** [[Kidney|Renal]]:
-*** [[Blood urea nitrogen]] or [[creatinine]] at least twice the upper limit of normal for laboratory
+*** [[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 for laboratory:
+** [[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
+** [[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>
+*** [[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>
 ==== 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
+* C[[cerebrospinal fluid|erebrospinal fluid]] cultures
 * Negative [[Serology|serologies]] for:
-** [[Rocky Mountain spotted fever]]
+** [[Rocky Mountain spotted fever|Rocky Mountain Spotted Fever]]
-** [[leptospirosis]]
+** [[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>
+** [[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>
 === 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>
+====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"
-!Disease presentation
+! align="center" style="background:#4479BA; color: #FFFFFF;" |Disease Presentation
-! colspan="2" |criteria
+! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Criteria
-!Definite case
+! align="center" style="background:#4479BA; color: #FFFFFF;" |Definite case
-!Suspected case
+! align="center" style="background:#4479BA; color: #FFFFFF;" |Suspected case
 |-
-! rowspan="2" |Streptococal TSS
+! rowspan="2" align="center" style="background:#DCDCDC;"|Streptococal TSS
 |A. Isolation of group A [[Streptococcus]]
 |1. From a [[sterile]] site
 . From a nonsterile body site
-| rowspan="2" |A1+B
+| rowspan="2" |A1 '''+''' B(complete)
-| rowspan="2" |A2+B
+| rowspan="2" |A2 '''+''' B(complete)
 |-
 |B. Clinical signs of severity
@@ Line 81: / Line 71: @@
 * [[Hypotension]]
 * Clinical and laboratory abnormalities (requires two or more of the following):
 ** [[Renal Failure]]
 ** [[Coagulopathy]]
 ** [[Hepatic failure]]
-** [[Acute respiratory distress syndrome]](ARDS)
+** [[Acute respiratory distress syndrome]] (ARDS)
-** Extensive tissue [[necrosis]], i.e. necrotizing fasciitis
+** Extensive tissue [[necrosis]] i.e. necrotizing fasciitis
 ** [[Erythematous]] [[rash]]
 |-
-! rowspan="2" |Necrotizing fasciitis
+! rowspan="2" align="center" style="background:#DCDCDC;"|Necrotizing fasciitis
 |A. Clinical Criteria
 |
@@ Line 102: / Line 91: @@
 *** [[Hepatic failure|Liver failure]]
 *** [[Renal failure]]
-| rowspan="2" |A+B1
+| rowspan="2" |A (complete) '''+''' B1
-| rowspan="2" |A+B2
-A+B3
+| rowspan="2" |A (complete) '''+''' B2
+A(complete) '''+''' B3
 |-
 |B. Isolation of group A [[Streptococcus]]
 |
-# Isolation of group A [[Streptococcus]] from a normally [[sterile]] body site
+# 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 B
+# [[Serological testing|Serologic]] confirmation of group A [[Streptococcus|streptococcal]] infection by a 4-fold rise against:
-# [[Histologic]] confirmation: [[Gram-positive cocci]] in a [[Necrotic tissue|necrotic soft tissue infection]]
+::a) streptolysin O b) [[DNase|DNase B]]
+:3. [[Histologic]] confirmation: [[Gram-positive cocci]] in a [[Necrotic tissue|necrotic soft tissue infection]]
 |}
@@ Line 121: / 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]]