Toxic Shock Syndrome: A Literature Review

Abstract

Toxic shock syndrome (TSS) is a rare, life-threatening, toxin-mediated infectious process linked, in the vast majority of cases, to toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes. The pathophysiology, epidemiology, clinical presentation, microbiological features, management and outcome of TSS are described in this review. Bacterial superantigenic exotoxins induces unconventional polyclonal lymphocyte activation, which leads to rapid shock, multiple organ failure syndrome, and death. The main described superantigenic exotoxins are toxic shock syndrome toxin-1 (TSST-1) and enterotoxins for Staphylococcus aureus and Streptococcal pyrogenic exotoxins (SpE) A, B, and C and streptococcal superantigen A (SsA) for Streptococcus pyogenes. Staphylococcal TSS can be menstrual or nonmenstrual. Streptococcal TSS is linked to a severe group A streptococcal infection and, most frequently, to a necrotizing soft tissue infection. Management of TSS is a medical emergency and relies on early detection, immediate resuscitation, source control and eradication of toxin production, bactericidal antibiotic treatment, and protein synthesis inhibiting antibiotic administration. The interest of polyclonal intravenous immunoglobulin G administration as an adjunctive treatment for TSS requires further evaluation. Scientific literature on TSS mainly consists of observational studies, clinical cases, and in vitro data; although more data on TSS are required, additional studies will be difficult to conduct due to the low incidence of the disease.

Keywords: Staphylococcus aureus; Streptococcus pyogenes; exotoxin; staphylococcal enterotoxin; streptococcal pyrogenic exotoxin; toxic shock syndrome toxin 1.

Figure 1

Empiric antimicrobial treatment of TSS [1,60]. TSS: toxic shock syndrome; m-TSS: menstrual TSS; nm-TSS: nonmenstrual TSS; NSTI: necrotizing soft tissue infection; MRSA: methicillin-resistant Staphylococcus aureus; ESBL: extended spectrum beta lactamase. ¹ High incidence of community-acquired MRSA, known carriage, household contamination, previous antibiotic therapy, recent hospital stay, and recent trip in a zone at risk. ² Previous antibiotic treatment in the last 6 months, travel in endemic area in the last 6 months, known carriage of ESBL strain, hospital stay in the last 3 months, and long institution stay.