Toxic shock syndrome

Toxic shock syndrome: Excerpt from Professional Guide to Diseases (Eighth Edition)

Toxic shock syndrome (TSS) is an acute bacterial infection caused by toxin-producing, penicillin-resistant strains of Staphylococcus aureus, such as TSS toxin-1 and staphylococcal enterotoxins B and C. Initially, the disease was thought to primarily affect menstruating women younger than age 30 and was associated with continuous use of tampons during the menstrual period; however, only about 55% of cases are associated with menses. TSS is fatal in 50% of cases.

Causes

Theoretically, tampons may contribute to development of TSS by introducing S. aureus into the vagina during insertion (insertion with fingers instead of the supplied applicator increases the risk) or traumatizing the vaginal mucosa during insertion, thus leading to infection.

When TSS isn’t related to menstruation, it appears to be linked to S. aureus infections, such as abscesses, osteomyelitis, and postsurgical infections. It's also associated with prior antibiotic use.

Risk factors include recent use of barrier contraceptives (diaphragms or vaginal sponges), childbirth, and surgery.

Signs and symptoms

Typically, TSS produces intense myalgias, fever over 104° F (40° C), vomiting, diarrhea, headache, decreased level of consciousness, rigors, conjunctival hyperemia, and vaginal hyperemia and discharge. Severe hypotension occurs with hypovolemic shock. Within a few hours of onset, a deep red rash develops — especially on the palms and soles — and later desquamates.

Major complications include persistent neuropsychological abnormalities, mild renal failure, rash, and cyanotic arms and legs.

Diagnosis

Diagnosis is based on several criteria: fever, hypotension, rash that peels after 1 to 2 weeks, and at least 3 organs with signs of dysfunction. In some cases, blood cultures may be positive for S. aureus. Organs with signs of dysfunction may include:

❑GI effects, including vomiting and profuse diarrhea

❑muscular effects, with severe myalgias or a fivefold or greater increase in creatine kinase levels

❑mucous membrane effects such as frank hyperemia

❑renal involvement with elevated blood urea nitrogen or creatinine levels (at least twice the normal levels)

❑liver involvement with elevated bilirubin, aspartate aminotransferase, or alanine aminotransferase levels (at least twice the normal levels)

❑blood involvement with signs of thrombocytopenia and a platelet count of less than 100,000/µl

❑central nervous system effects such as disorientation without focal signs.

Negative results on blood tests for Rocky Mountain spotted fever, leptospirosis, and measles help rule out these disorders.

Treatment

Treatment involves examination and removal of foreign material, such as tampons, vaginal sponges, or nasal packing; and drainage of any identified site of infection such as surgical wounds. Antistaphylococcal antibiotics that are beta-lactamase resistant, such as oxacillin and nafcillin, are given I.V. To reverse shock, expect to replace fluids with saline solution and colloids, as ordered. Blood pressure support and dialysis may be necessary. In some cases, I.V. immunoglobulin may be required.

Special considerations

❑Instruct women to change their tampons frequently and to always wash their hands before and after doing so.

❑Monitor the patient's vital signs frequently.

❑Administer antibiotics slowly and strictly on time. Be sure to watch for signs of penicillin allergy.

❑Check the patient's fluid and electrolyte balance.

❑Obtain specimens of vaginal and cervical secretions for culture of S. aureus, or other sites of TSS infection.

❑Implement standard precautions.

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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