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

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.

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. A criteria list have been established by United States 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.

An illness 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
• 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.

Laboratory Criteria for Diagnosis

Negative results on the following tests, if obtained:

• Blood or cerebrospinal fluid cultures blood culture may be positive for Staphylococcus aureus)
• Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles

Case Classification

• Probable: A case which meets the laboratory criteria and in which four of the five clinical criteria described above are present

• 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 occurshttps

Streptococcal TSS

There is a subtle defference 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

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	Hypotension Clinical and laboratory abnormalities (requires two or more of the following): Renal impairment Coagulopathy Liver abnormalitie Acute respiratory distress syndrome 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: a) Death b) Shock (systolic blood pressure <90 mm of Hg). c) Disseminated intravascular coagulopathy d) Failure of organ systems a. respiratory failure b. liver failure c. renal failure	A+B1	A+B2 A+B3
	B. Isolation of group A Streptococcus	Isolation of group A Streptococcus from a normally sterile body site serologic confirmation of group A streptococcal infection by a 4-fold rise against: a) streptolysin O b) DNase B histologic confirmation: Gram-positive cocci in a necrotic soft tissue infection

References

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