Case #1: Rory Staunton
Pathophysiology of toxic shock syndromes
Clinical presentation: Overview
Clinical Presentation of Staph TSS
|“Strawberry tongue” in staphylococcal toxic shock syndrome (Drage 1999). Hyperemia of the mucus membranes may be especially useful in people with darker skin color, which can mask the erythematous blanching rash.|
Clinical Presentation of Strep TSS
Strep TSS manifesting with primarily toxigenic symptoms
Strep TSS manifesting with focal infection
|Pain out of proportion to exam is the most sensitive physical finding in necrotizing fasciitis. It is also useful because it is typically present early (Tobin 2009). Late in the disease course, necrosis of the nerves may produce central anesthesia.|
Staph TSS may be misdiagnosed as garden-variety septic shock (e.g., Case #2 above was initially diagnosed as septic shock due to cellulitis). Prominent gastrointestinal symptoms or erythematous rash may be helpful clues if present. The degree of illness is typically out of proportion to the focus of infection. Poor response to standard treatments for sepsis can also suggest TSS.
|A violaceous bullae should always raise the question of necrotizing fasciitis (Drage 1999).|
(c) Pregnancy-related Strep TSS
Formal diagnostic criteria for TSS
Once the full range of symptoms become manifest, the diagnosis is usually straightforward. However, the patient may have developed irreversible organ failure by the time this occurs.
Practical approach to
diagnosing suspecting TSS
Conclusion: Red flags for TSS
- Systemic illness plus a diffuse blanchable erythematous rash.
- Younger person initially develops a gastroenteritis-like illness and subsequently progresses to septic shock without alternative explanation.
- Severe focal soft tissue pain out of proportion to examination plus systemic toxicity (e.g., high fever or elevated shock index).
- Peripartum septic shock.
- Septic shock due to proven or probable Group A streptococcal infection (e.g., cellulitis, necrotizing fasciitis), with sepsis severity out of proportion to the infectious source.