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Toxic Shock Syndrome

- Discussion:
    - toxic shock is an acute febrile syndrome that was originally described in association with the use of highly absorbent tampons but is now recognized to occur as a postoperative complication of many different surgical procedures;
    - toxins produced by staphylococcus aureus (or streptococcus) are probably responsible for this syndrome;
           - migmatoxin produced by staph aureus, may be the most importnat toxin in toxic shock syndrome;
    - clinical features:
           - streptococcal toxic shock syndrome:
                    - isolation of group A streptococci (froma sterile site or from a nonsterile body site)
                    - hypotension
                    - coagulopathy
                    - soft-tissue necrosis
                    - myositis or gangrene: more than 50% of cases of streptococcal toxic shock develop into necrotizing fasciitis or myositis
                    - hepatic involvement
                    - renal impairment
                    - generalized erythematous macular rash
                    - acute respiratory distress syndrome
                    - ref: Surviving streptococcal toxic shock syndrome: a case report
           - staphylococcal toxic shock syndrome:
                    - includes the above in addition to fever and a rash with desquamation;
                    - soft-tissue necrosis is not common
                    - ref: Postoperative Toxic Shock Syndrome

- Clinical Presentation:
    - dx is based on clinical findings & requires following criteria:
    - fever greater than 38.9 C (102 F), hypotension (systolic pressure of 90 mm Hg or less), a diffuse macular rash, and evidence of multiple (three or more) organ system dysfunction;
    - local signs of wound infection are typically absent or minimal which unfortunately may lead to delayed diagnosis;
    - rash is usually followed by desquamation after 1 to 2 weeks;

- Treatment:
    - aggressive fluid administration;
    - parenteral antibiotics;
           - clindamycin 600 mg IV q 8 hrs;
                 - effective against streptococcus and most staph aureus.
                 - may shut down toxin production from strep;
                 - ref: Growth phase-dependent effect of clindamycin on production of exoproteins by Streptococcus pyogenes
           - penicillin G (4 million units IV q 4 hours);
    - wound debridement w/ removal of any foriegn bodies or metal implants;
    - some advocate systemic corticosteroids as well

Posttraumatic toxic shock syndrome. Knudson P, Charney M, Salcido D. Trauma 1988;28(1):121-123.

Fatal toxic shock syndrome as complication of orthopaedic surgery.  

Toxic shock syndrome in association with group A streptococcal infection of a total knee joint after a total knee arthroplasty.

Toxic shock syndrome in patients with external fixators.   

Toxic shock syndrome in association with group-A streptococcal infection of a knee joint after a total knee arthroplasty: a case report.

Non-menstrual toxic shock syndrome complicating orthopaedic surgery.

Streptococcal Toxic Shock Syndrome Presenting as Septic Knee Arthritis in a 5-Year-Old Child.

Case records of the Massachusetts General Hospital. Case 2-2009. A 25-year-old man with pain and swelling of the right hand and hypotension.

Streptococcal Toxic-Shock Syndrome: Spectrum of Disease, Pathogenesis, and New Concepts in Treatment