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  • Toxic shock syndrome (TSS) is an acute, toxin-mediated illness characterized by fever, erythematous rash, hypotension, multiorgan involvement, and desquamation.
  • Most cases of TSS have been associated with Staphylococcus aureus, However, group A Streptococcus (GAS) can cause a similar disease known as streptococcal TSS (STSS).
  • Menstrual and nonmenstrual cases of TSS are now reported with almost equal frequency. Predisposing factors for nonmenstrual TSS are surgical and nonsurgical trauma, burns, and postpartum conditions. Predisposing factors for STSS are varicella, NSAID use, and deep-seated GAS infections.
  • TSS is a rare disease and is less common in children than adults. However, it is serious and can be life-threatening unless diagnosed rapidly and managed aggressively.
  • STSS patients may have severe pain and hyperesthesia out of proportion to the degree of skin involvement.
  • Abnormal laboratory values reflect the multisystem involvement in TSS.
  • Management depends on prompt recognition, identification, and removal of the infectious focus. In addition, antibiotics and hemodynamic support are essential.
  • Clindamycin has been recommended as the antibiotic of choice for both TSS and STSS (along with penicillin G for GAS).
  • The most important initial therapy is aggressive volume replacement. Crystalloids or fresh frozen plasma may be used for the management of hypotension, with pressors added if fluids alone are not sufficient.
  • TSS can mimic many common diseases and should be considered in any patient who has unexplained fever, rash, and a toxic condition out of proportion to local findings. Early recognition is critical because the clinical course can be fulminant.


Toxic shock syndrome (TSS) is a rare acute febrile disease characterized by fever, diffuse erythroderma (that later desquamates), vomiting, abdominal pain, diarrhea, myalgia, and nonspecific neurologic abnormalities.1 It can progress rapidly to hypotension, multiorgan failure, and death.2


TSS was first described in 1978 in seven children with Staphylococcus aureus infections. In 1980, TSS was noted in menstruating women. An epidemic developed associated with continuous tampon use by women who had vaginal colonization with toxin-producing strains of S. aureus. With the withdrawal of superabsorbent tampons from the market, menstrual TSS is now rare. However, nonmenstrual TSS continues to occur in children and adults; it is most commonly associated with cutaneous infections. Menstrual and nonmenstrual TSS are now reported in almost equal frequency.1 TSS is more common in adults than children.


Since the late 1980s, with the resurgence of highly invasive streptococcal infections, a toxic shocklike syndrome has been reported. Most authors accept the abbreviation “sTSS” to distinguish streptococcal from staphylococcal TSS.3


Because TSS and sTSS are syndromes, the diagnosis is made when several clinical signs are found together. The Centers for Disease Control and Prevention (CDC) have formulated case definitions for both TSS and sTSS (Tables 62–1 and 62–2).4,5

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Table 62-1. Toxic Shock Syndrome: Centers for Disease Control Case Definition

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