Infectious Disease

Toxic shock syndrome

Toxic shock syndrome is a rapidly progressive toxin-mediated illness caused by Staphylococcus aureus or group A Streptococcus, with fever, diffuse rash, hypotension and multi-organ dysfunction; treat it as an emergency with sepsis resuscitation, immediate source control and specialist antimicrobial therapy.

In a nutshell

Toxic shock syndrome is a rapidly progressive toxin-mediated emergency caused by Staphylococcus aureus or group A Streptococcus. Fever, diffuse erythema, vomiting or diarrhoea, hypotension and multi-organ dysfunction should prompt immediate sepsis resuscitation, removal of a tampon or other source, urgent surgical review when needed, broad-spectrum IV antibiotics with clindamycin anti-toxin cover and critical-care support; consider IVIG with specialist advice in severe streptococcal disease.

Classic presentation

A menstruating person using a tampon develops abrupt fever, severe myalgia, vomiting, a diffuse sunburn-like rash, dizziness and hypotension; alternatively, invasive GAS TSS presents with severe soft-tissue pain, shock and rapidly progressive organ dysfunction.

Key points

Superantigens cause widespread T-cell activation and cytokine-mediated distributive shock.
Search for and remove the source immediately: tampon, menstrual cup, packing, wound, abscess or deep soft-tissue infection.
Treat as high-risk sepsis; in adults, NICE recommends broad-spectrum IV antibiotics within 1 hour and 250 mL crystalloid boluses with reassessment up to 1,000 mL unless contraindicated.
Use empiric cover for both Staphylococcus aureus and group A Streptococcus, add clindamycin for anti-toxin effect and narrow with microbiology advice.
Consider IVIG with specialist input in severe streptococcal TSS, especially necrotising fasciitis or refractory shock; it never replaces source control.
Desquamation is late and negative blood cultures do not exclude toxin-mediated disease.

First-line investigation

Clinical diagnosis and NEWS2/severity assessment, blood cultures and organ-function bloods if they do not delay treatment, plus immediate examination for a foreign body, wound or deep soft-tissue source.

Management

Recognise and resuscitate

Treat suspected TSS as high-risk sepsis: oxygen, monitoring, IV access, cultures if no delay, 250 mL crystalloid boluses with reassessment, and broad-spectrum IV antibiotics within 1 hour for adults at high risk.^4,5
Call critical care, microbiology or infectious diseases and senior surgical help early; use vasopressors and organ support if shock persists.^4,2

Control the source and start anti-toxin treatment

Remove a tampon, menstrual cup or nasal packing immediately; drain collections and urgently explore or debride suspected necrotising soft-tissue infection.^2,3
Start IV cover for Staphylococcus aureus and group A Streptococcus, with local MRSA advice, and add clindamycin early for anti-toxin effect; narrow after microbiology review.^5,1,6

Manage invasive GAS and organ failure

Consider IVIG with infectious-diseases or microbiology and critical-care advice for severe streptococcal TSS, especially with necrotising fasciitis or refractory shock.^1,6
Reassess lactate, NEWS2, urine output, airway, breathing and organ function; if no response within 1 hour of an intervention, obtain in-person senior and critical-care review.^4,5
Notify probable or confirmed iGAS urgently to the health protection team so that contact assessment and prophylaxis can be directed by public health colleagues.^3,7

Prevent recurrence

Give source-specific follow-up and advise on avoiding implicated menstrual or barrier products after specialist review; keep wounds clean and return urgently for recurrent systemic symptoms.²

Exam traps

Do not wait for desquamation, positive blood cultures or toxin testing before treating.
A tampon or nasal packing must be removed and a necrotising focus must be surgically assessed; source control is part of treatment.
Severe pain out of proportion, rapid progression, bullae or crepitus suggest necrotising fasciitis and require urgent surgery.
A beta-lactam alone is inadequate for suspected toxin-mediated TSS; use specialist anti-toxin therapy and broad initial organism cover.
Do not give IVIG routinely to every suspected case; consider it with specialist input for severe streptococcal disease.
Probable iGAS should be notified urgently even without microbiological confirmation when the clinical presentation is severe and GAS is the most likely cause.

Illustrations

Desquamation of the palmsClinical photograph showing bilateral palmar desquamation during recovery from toxic shock syndrome.Pandit K et al., Annals of Medicine and Surgery (2020), CC-BY-4.0 · CC-BY-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.