Toxic Shock Syndrome : Wheeless' Textbook of Orthopaedics

- Discussion:
- toxic shock is an acute febrile syndrome that was originally described in association with the use of highly absorbent tampons but is now recognized to occur as a postoperative complication of many different surgical procedures;
- toxins produced by staphylococcus aureus (or streptococcus) are probably responsible for this syndrome;
- migmatoxin produced by staph aureus, may be the most importnat toxin in toxic shock syndrome;
- clinical features:
- streptococcal toxic shock syndrome:
- isolation of group A streptococci (froma sterile site or from a nonsterile body site)
                    - hypotension
- coagulopathy
- soft-tissue necrosis
- myositis or gangrene: more than 50% of cases of streptococcal toxic shock develop into necrotizing fasciitis or myositis
                    - hepatic involvement
- renal impairment
- generalized erythematous macular rash
- acute respiratory distress syndrome
                    - ref: Surviving streptococcal toxic shock syndrome: a case report
           - staphylococcal toxic shock syndrome:
- includes the above in addition to fever and a rash with desquamation;
- soft-tissue necrosis is not common
                    - ref: Postoperative Toxic Shock Syndrome

- Clinical Presentation:
- dx is based on clinical findings & requires following criteria:
- fever greater than 38.9 C (102 F), hypotension (systolic pressure of 90 mm Hg or less), a diffuse macular rash, and evidence of multiple (three or more) organ system dysfunction;
- local signs of wound infection are typically absent or minimal which unfortunately may lead to delayed diagnosis;
- rash is usually followed by desquamation after 1 to 2 weeks;

- Treatment:
- aggressive fluid administration;
- parenteral antibiotics;
- clindamycin 600 mg IV q 8 hrs;
- effective against streptococcus and most staph aureus.
                 - may shut down toxin production from strep;
                 - ref: Growth phase-dependent effect of clindamycin on production of exoproteins by Streptococcus pyogenes
           - penicillin G (4 million units IV q 4 hours);
- wound debridement w/ removal of any foriegn bodies or metal implants;
- some advocate systemic corticosteroids as well