Toxic Shock Syndrome after Surgery: Case Presentation and Systematic Review of the Literature

Abstract

Toxic shock syndrome (TSS) is an underrecognized but highly fatal cause of septic shock in postoperative patients. Although it may present with no overt source of infection, its course is devastating and rapidly progressive. Surgeon awareness is needed to recognize and treat this condition appropriately. In this paper, we aim to describe a case of postoperative TSS, present a systematic review of the literature, and provide an overview of the disease for the surgeon.

Methods: A systematic review of the literature between 1978 and 2018 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the keywords "toxic shock syndrome" and "surgery." Variables of interest were collected in each report.

Results: A total of 298 reports were screened, and 67 reports describing 96 individual patients met inclusion criteria. Six reports described a streptococcal cause, although the vast majority attributed TSS to Staphylococcus aureus (SA). The mortality in our review was 9.4%, although 24% of patients suffered some manner of permanent complication. TSS presented at a median of 4 days postoperatively, with most cases occurring within 10 days.

Conclusions: Surgeons must maintain a high index of suspicion for postoperative TSS. Our review demonstrates that TSS should not be excluded despite young patient age, patient health, or relative simplicity of a procedure. Symptoms such as fever, rash, pain out of proportion to examination, and diarrhea or emesis should raise concern for TSS and prompt exploration and cultures even of benign-appearing postoperative wounds.

Fig. 1.

Initial patient presentation and surgery. A, Preoperative image demonstrating fungating scalp mass. B, Defect following excision of mass and titanium mesh cranioplasty. C, Postoperative image demonstrating ALT flap coverage of defect with a single drain in place.

Fig. 2.

Desquamation occurred approximately 19 days after surgery. A and B demonstrate the patient’s hands with panel B showing desquamation of the palms. The patient had removed some of the desquamated skin on his palms when the pictures were taken.

Fig. 3.

Descriptive statistics of collected variables. A, Frequency distribution of patient age (in 5-year increments). Most patients were between 21 and 40 years of age. B, Distribution of days to onset of TSS symptoms or admission. The red bars represent the median (4 days) ± the interquartile range (6.75 days). C, Number of reports by decade. Most reports were published within the first decade since recognition of TSS. D, Frequency distribution of surgical procedure specialties preceding onset of TSS.

Fig. 4.

Schematic of normal T-cell activation and abnormal T-cell activation induced by superantigen. Note that more inflammatory markers are secreted downstream than are shown in the figure.