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.
Overview:
Although the best 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 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, although the imaging technique lacks specificity in the diagnosis of TSS related complications.[1][2]
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[3].
Staphylococcus aureus antibody testing
Presence of Staphylococcus aureus in the absence of an acute-phase antibody can be highly suggestive of Staphylococcal TSS.
Diagnostic Criteria
Toxic Shock Syndrome (Other Than Streptococcal) (TSS)
Clinical Criteria
The diagnosis of 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 (CDC) for epidemiologic studies on 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.[4]
TSS illness diagnosis can be mad 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:
- Muscular:
- Severe myalgia
- Increase creatine phosphokinase (CPK) level at least twice the upper limit of normal
- Mucous membrane:
- Renal:
- Blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory
- 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:
- 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.[5][6]
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).[8]
| 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 | A2+B |
| B. Clinical signs of severity |
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| Necrotizing fasciitis | A. Clinical Criteria |
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A+B1 | A+B2
A+B3 |
| B. Isolation of group A Streptococcus |
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References
- ↑ Kim KT, Kim YJ, Won Lee J, Kim YJ, Park SW, Lim MK, Suh CH (2011). "Can necrotizing infectious fasciitis be differentiated from nonnecrotizing infectious fasciitis with MR imaging?". Radiology. 259 (3): 816–24. doi:10.1148/radiol.11101164. PMID 21406630.
- ↑ Malghem J, Lecouvet FE, Omoumi P, Maldague BE, Vande Berg BC (2013). "Necrotizing fasciitis: contribution and limitations of diagnostic imaging". Joint Bone Spine. 80 (2): 146–54. doi:10.1016/j.jbspin.2012.08.009. PMID 23043899.
- ↑ Stamenkovic I, Lew PD (1984). "Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy". N. Engl. J. Med. 310 (26): 1689–93. doi:10.1056/NEJM198406283102601. PMID 6727947.
- ↑ 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).