AKT · Infections/Sepsis, fever & healthcare-associatedlow yield

Toxic shock syndrome

Superantigen-mediated toxaemia — Staphylococcus aureus (TSST-1) or group A Streptococcus

Overview

A fulminant toxin-mediated illness in which bacterial superantigens (staphylococcal TSST-1, or group A streptococcal exotoxins) trigger massive cytokine release, causing high fever, a diffuse erythematous rash, hypotension and rapid multi-organ failure. Classically linked to tampon use or wound/skin infection (staphylococcal) or to invasive group A strep (often with necrotising fasciitis). It is an emergency: remove the source, resuscitate, and give antibiotics ± IVIG.

Recognise

Sudden high fever, diffuse macular ERYTHRODERMA ('sunburn' rash), hypotension and multi-organ involvement (renal, hepatic, GI, CNS, muscle); DESQUAMATION of palms/soles 1–2 weeks later
Staphylococcal: tampon use, nasal packing, surgical/skin wounds (often culture-negative blood — toxin-mediated). Streptococcal: invasive GAS, frequently with necrotising fasciitis/soft-tissue infection (positive cultures)
Rapid progression to shock and multi-organ failure

Red flags

Hypotension + multi-organ failure → emergency resuscitation/critical care
Streptococcal TSS with necrotising fasciitis (pain out of proportion, rapidly spreading) → urgent surgical debridement

Differentials & how to tell them apart

Septic shock (other organism)a source with positive cultures; TSS is toxin-mediated with the erythroderma/desquamation pattern

Staphylococcal scalded skin syndromeblistering/desquamation in young children, no shock

Drug reaction (DRESS/SJS) / Kawasaki diseasedifferent rash/criteria; Kawasaki in young children

Investigations

Clinical diagnosis (CDC criteria: fever, rash, hypotension, ≥3 organ systems, desquamation); cultures (wound/blood — often negative in staphylococcal), inflammatory markers, U&Es/LFTs/CK/coagulation (multi-organ); remove and culture any source (tampon, packing, wound); imaging if necrotising fasciitis suspected.

Management

Resuscitate + remove the source + antibiotics with clindamycin (± IVIG); debride necrotising fasciitis

1Recognise the toxin-mediated picture — fever + erythroderma + hypotension + multi-organ failure (later palmar/plantar desquamation), with a staphylococcal (tampon/wound) or streptococcal source. Resuscitate and REMOVE/control the source.Gate: Add clindamycin (a protein-synthesis inhibitor) to switch OFF toxin production; streptococcal TSS with necrotising fasciitis needs urgent surgical debridement, not antibiotics alone.
2IVIG for severe/streptococcal disease; critical-care support for multi-organ failure; treat the underlying soft-tissue infection.

Resuscitate (IV fluids ± vasopressors) + REMOVE THE SOURCE — remove the tampon/packing, debride/drain the wound — source removal is essential

Antibiotics: anti-staphylococcal/streptococcal + a protein-synthesis inhibitor (clindamycin) to switch off toxin production — clindamycin reduces exotoxin synthesis; cover staph/strep per setting

IVIG for severe/streptococcal TSS — neutralises superantigens in severe cases

Surgical debridement for necrotising fasciitis — the streptococcal association — don't delay surgery

Key points

Fever + diffuse 'sunburn' erythroderma + hypotension + multi-organ failure (then palm/sole desquamation) = toxic shock syndrome (superantigen). Staph (tampon/wound, cultures often negative) vs strep (invasive GAS + necrotising fasciitis). Resuscitate + REMOVE the source + antibiotics + CLINDAMYCIN (stops toxin) ± IVIG; debride nec fasc.

Monitor & prognosis

Haemodynamics/organ function, source control, desquamation; recurrence risk (avoid tampons after staph TSS).

Rapidly progressive; mortality significant (higher for streptococcal), better with prompt source control + clindamycin/IVIG.

Source: UKHSA; cross-ref dermatology (nec fasc/SSSS), acute_care (shock)