Toxic shock syndrome history and symptoms

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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

Toxic shock syndrome (TSS) is characterized by sudden onset of fever, chills, vomiting, diarrhea, muscle aches and rash. It can rapidly progress to severe and intractable hypotension and multisystem dysfunction. Desquamation, particularly on the palms and soles can occur 1-2 weeks after onset of the illness.

History and symptoms of patients vary based on the organism responsible for the shock.

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] are suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

A positive family history of [disease/malignancy] may be present.

History

It is necessary to obtain a detailed and thorough history from the patient to diagnose the type of TSS and determine its severeness. Specific areas of focus when obtaining a history from the patient include

It provides insight into cause, precipitating factors and associated comorbid conditions. Complete history will help determine the correct therapy and helps in determining the prognosis. TSS patients may be disoriented due to encephalopathy complication therefore the patient interview may be difficult. In such cases history from the care givers or the family members may need to be obtained. Specific histories about the symptoms (duration, onset, progression), associated symptoms, drug usage have to be obtained. Specific areas of focus when obtaining the history, are outlined below:

• TSS other than Streptococcal:
  • history of tampon usage during mensturation
  • Initial skin and mocousal manifestations include diffuse, red, macular rash resembling sunburn that can also involve the palms and soles(which is characteristic of erythroderma that can involve both mucous membranes and skin.
  • Generalized myalgias and weakness
  • Generalized flu like symptoms
• Associated symptoms(lethargy, fever, confusion)
• Medications
• History of Trauma
• Symptoms of other organ failure (renal failure, liver failure, adrenal failure)
• Poisons or chemicals ingested
• Co-morbid conditions like diabetes, immunodeficiency
• severe infections
• Any dehydration history for severe loss of fluids
• Exposure to toxic substances
• Trauma

Symptoms

Associated symptoms can provide clues as to the cause of encephalopathy.

• Confusion or agitation
• Changes in behavior and personality
• Progressive cognitive decline
• Forgetfulness
• Disorientation
• Insomnia
• Muscle stiffness or rigidity
• Tremor (particularly a flapping tremor of the hands)
• Difficulty speaking
• Asterixis (rapid momentary loss of tone in the muscles)
• Uncontrollable movements or seizures
• Stupor or coma

Associated symptoms

Symptoms associated with other diseases and co-morbid conditions.

• Hematemesis
• Nausea and vomiting
• Severe headache
• Dyspnea
• Visual disturbances
• Palpitations, angina
• Hematuria

Staphylococcal TSS

Staphylococcal TSS can be divided into 2 major categories based on the disease cause: menstrual and non-menstrual illness. Although these 2 types are different from each other in the terms of cause and pathogenesis, their clinical manifestations are pretty much the same.

Clinical manifestations of Staphylococcal TSS include a variety of shock symptoms, and hypersensitivity that is associated with the disease:

• These generalized signs may begin during the first 2 days of hospitalization; patients may develop diffuse erythroderma, severe watery diarrhea, decreased urine output, cyanosis, and edema of the extremities.
• Hypotension: It usually happens in a rapid onset, with a systolic blood pressure of ≤90 mmHg for adults or less than fifth percentile by age for children <16 years of age. This hypotension can be unresponsive to fluid infusion even large amounts of isotonic intravenous fluids and can persist for several days.

• Skin manifestations: These manifestations are usually due to hypersensitivity reactions. they can be very variable. The initial erythroderma can involves both mucous membranes and skin. It's main characteristics involve diffuse, red, macular rash resembling sunburn that can also involve the palms and soles. It can be fleeting and subtle. Conjunctival-scleral hemorrhage and hyperemia of the vaginal and oropharyngeal mucosa can be found while mucosal involvement is associated with skin manifestations. Superficial ulcerations can also occur on the mucous membranes especially in more advanced forms of the disease. It can lead to petechiae, vesicles, and bullae development. Non-pitting edema can develop as a result of increases in interstitial fluid. Late-onset skin findings include pruritic maculopapular rash and palm/soles desquamation which particularly begins 1-3 weeks after disease beginning. As a matter of late onset characteristic of desquamation, it can not be used as a good diagnostic feature. Hair and nail loss may also occur in some cases one to two months after the onset of disease, with regrowth by six months.

• Multiorgan system involvement: All body organ systems can be involved during disease, which can lead to specific organ related symptoms. Many patients complaint of generalized myalgias and weakness as their primary chief complaints. In these patients, usually elevated levels of creatine phosphokinase (CPK) concentration can be detected. Gastrointestinal complaints are also common, particularly watery diarrhea. Both prerenal and intrinsic renal failure can occur. Renal failure can lead to metabolic abnormalities such as hypocalcemia, hyponatremia, hypoalbuminemia, and hypophosphatemia.

• Encephalopathy: Cerebral edema as a complication of TSS can lead to encephalopathy which is fatal and manifested by disorientation, confusion, or seizure activity,. Other central nervous system (CNS) findings may be present rarely in patients for instance persistent neuropsychological sequels can develop such as headaches, memory loss, and poor concentration . Neurologic symptoms such as somnolence, confusion, irritability, agitation, and hallucinations may occur as a result of cerebral edema and its following ischemia. Other symptoms that can be found in patients with encephalopathy due to TSS include pleural effusions and pulmonary edema, cardiac dysfunction, hepatic failure, and hematologic abnormalities, especially anemia and thrombocytopenia.

Streptococcal TSS

Streptococcal TSS may occur with infection at any site, but most often occurs in association with infection of a cutaneous lesion, specially with local blunt trauma injury and penetrating tissue trauma that can lead to necrotizing fasciitis (NF). NF mostly occurs in the lower limb, followed by the upper limb. Although the invasive nature of disease is well known, most of the time origin of entry and source of infection can not be identified that lead to a significant problem,. The symptoms and signs of TSS develop rapidly, usually in otherwise healthy individuals. The disease should be diagnosed based on the clinical findings primarily. In most cases of NF-related TSS fatality rate may exceed 50%.

Patients with GAS-associated NF may present with non-specific signs of disease when they primarily administered. This can make it difficult to differentiate their disease from a simple cellulitis. NF can cause severe pain and local tenderness which is disproportionate to other physical findings; this can be used as a clinical hallmark for differentiating NF from other superficial infections. Late signs that present themselves with disease progression include tense edema and bullae development that seem bluish. Edema and bluish bullae indicate significant tissue necrosis and severity of the disease.,.

Toxic shock syndrome signs and symptoms are exactly like Staphylococcal TSS and include fever, hypotension, and skin manifestations (as mentioned before). Also non-specific signs like chills, malaise, sore throat, fatigue, myalgias, headache, abdominal pain, diarrhea, vomiting and orthostatic hypotension with dizziness or syncope may be seen.

Clostridium sordellii TSS

This is a rare cause of TSS but maybe the most dangerous cause with a rapid onset. There are a variety of symptoms include skin infection, bacteremia, and organ specific infections such as pneumonia, empyema, endocarditis, septic arthritis, and surgical site infection,, . C. sordellii toxic shock is characterized by rapid occurrence of severe disease symptoms with shock; in these cases TSS mostly occurs in previously healthy individuals. The clinical presentation generally consists of specific infection related manifestations including profound leukocytosis, hemoconcentration, edema, effusions,and followed by multiorgan failure and shock.

Disease primary symptoms include nonspecific symptoms that may be misdiagnosed with viral infections like flu and may include nausea, vomiting, lethargy, influenza-like symptoms, and abdominal tenderness,.

Disease progression to the shock and severe symptoms occurs within hours. The nature of disease which starts with nonspecific symptoms and its rapid progression toward shock make in really hard to diagnose it in early stages; that may be the reason of disease's high mortality .

• diagnostic clues based on signs and symptoms of disease

	diagnostic clues in C. sordellii	causes
generalized symptoms	hypotension tachycardia absence of fever	generalized toxic-mediated changes
diffuse edema	generalized	rapid development of generalized and massive tissue edema due to toxin-mediated changes and increase in vascular permeability
effusion	pleural pericardial peritoneal	due to capillary leak from toxin-mediated changes in the vascular endothelium and ahypoalbuminemia
laboratory changes	leukocytosis hemoconcentration	Profound leukocytosis (leukemoid reaction) consisting of white blood cell (WBC) count >50,000 cells/microL, which can increase to 200,000 cells/microL within 48 hours An increased percentage of mature and immature neutrophils and increased absolute numbers of lymphocytes and monocytes Leukemoid reaction is highly predictive of mortality Hematocrit levels up to 80 percent have been reported

• TSS different causes and their symptoms

	type	symptoms
Staphylococcal TSS	menstural	Skin manifestations: erythroderma Conjunctival-scleral hemorrhage and hyperemia of the vaginal and oropharyngeal mucosa
	non-menstural
Streptococcal TSS	GAS-related NF	skin and cutaneous lesions: necrotizing fasciitis (NF) tense edema and bluish bullae with disease progression General Shock Signs: fever, hypotension, chills, malaise, sore throat, fatigue, myalgias, headache, abdominal pain, diarrhea, vomiting and orthostatic hypotension with dizziness or syncope
Clostridium sordellii TSS	-	nonspecific primary symptoms that may be misdiagnosed with viral infections like flu (nausea, vomiting, lethargy, influenza-like symptoms, and abdominal tenderness) skin infection, bacteremia, and organ specific infections such as pneumonia, empyema, endocarditis, septic arthritis, and surgical site infection

References

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