Toxic shock syndrome diagnostic criteria

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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.

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:
    • Vaginal
    • Oropharyngeal
    • Conjunctival
  • 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.
    • Total bilirubin
    • Alanine aminotransferase
    • Aspartate aminotransferase
  • Hematologic:
    • Platelets less than 100,000/mm3
  • Central nervous system:
    • Disorientation or alterations in consciousness without focal neurologic signs.

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:
  • Rocky Mountain Spotted Fever
  • Leptospirosis
  • Measles

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).

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)
	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
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
	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

References

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