- Recognize the common clinical features of toxic shock syndrome
- Manage a patient with suspected toxic shock syndrome
Click here for a interactive 5 min version of this case on the Human Diagnosis Project.
40 yo M who presents with a fever, sore throat, and rash. He first developed fevers, chills, sore throat, and a productive cough 2 weeks ago while traveling in Europe. He notes multiple sick contacts at that time. He has had a cough productive of green/yellow sputum and severe throat pain limiting his ability to swallow but denies any chest pain or shortness of breath. Over the past 12 hours, he developed a nontender, nonpruritic red rash that started concurrently on his chest, back, and upper thighs. He reports myalgias and arthralgias without any noted joint swelling or redness.
He has a history of bipolar disorder and takes lamotrigine. He has taken ibuprofen and APAP sparingly over the past week without relief of his symptoms. He uses ETOH and THC socially.
His physical exam is notable for T of 39.2C, HR 96, RR 20, BP 100-110s/40-60s, SaO2 95% on RA. He appears well and in no distress. His posterior oropharynx showed erythematous 2+ tonsils with tonsillar exudates. He has crackles and tubular breath sounds in the R upper lung fields. His skin is notable for a flat, erythematous, blanching patch over his chest, neck and abdomen without a papular component and spares the palms and soles.
His initial labs are notable for Na of 133, WBC of 16 with left shift, normal lactate (full labs). A flu swab was negative and rapid strep test was positive.
His CXR shows:
He had a CT neck which did not show any peri-tonsillar or retropharyngeal abscess.
What is your differential for his rash?
He has a right upper lobe pneumonia which likely explains his sepsis physiology, but does not explain his diffuse rash. Our differential included:
- Scarlet fever (given positive rapid strep test)
- Drug rash and fever (with a focus on lamotrigine)
- Viral exanthem
He was prescribed levofloxacin for presumed streptococcal (GPCs in pairs and chains) pneumonia and sent home from the ED. He was called back the next day after his blood cultures grew GPCs in pairs in chains.
On representation, his vitals are now T 36.1C, HR 96, BPs 80s/50s, SaO2 94% on RA. He now appears ill and is in moderate distress. His rash is more erythematous, but otherwise his exam is unchanged. Labs are notable for:
– Cr of 1.3 -> 2.1, BUN 12 -> 26
– WBC of 16 -> 22 , hct 34 -> 30, plts 192 ->151
– Lactate 1.1 -> 2.3
– Tbili rising from 0.6 -> 1.5, other LFTs within normal limits
– INR 1.5, PTT 36, fibrinogen 325
How would you manage this patient? What are you concerned about?
He is now bacteremic and developing shock physiology. This could be progressive septic shock from a streptococcal pneumonia and bacteremia or streptococcal toxic shock syndrome (TSS).
Though S. pneumoniae is the most common cause of community acquired pneumonia, he had a rapid strep test (GAS test) that was positive, making GAS pneumonia/bacteremia also a possibility. Levofloxacin has variable activity against GAS. He should receive IVF boluses for his hypotension and be switched to a broad spectrum IV beta-lactam antibiotic. If there is clinical concern for TSS, IV clindamycin should be started for anti-toxin effect.
He was started on IV ceftriaxone and IV clindamycin. His BPs failed to respond to 4 L of IVF hydration and was transferred to the ICU. He was broadened to IV vancomycin, IV piperacillin-tazobactam and continued on IV clindamycin. He required low doses of norepinephrine for vasopressor support.
His blood cultures ultimately grew out beta-hemolytic strep (Group A Streptococcus, GAS) that was sensitive to fluoroquinolones and cephalosporines. He cleared his blood cultures on HD2. TTE did not show any vegetations concerning for endocarditis. He underwent a bronchoscopy of his RUL pneumonia, which also grew out Group A Streptococcus.
Toxic shock syndrome (TSS) can be caused by both Streptococcal species and Staphylococcus aureus. The clinical syndrome is caused by bacterial toxins that result in immune activation and cytokine production. There are subtle differences between staphylococcal toxic shock and streptococcal toxic shock syndrome and we will only address streptococcal toxic shock syndrome here (see Additional Learning for staphylococcal toxic shock).
Streptococcal TSS most commonly occurs with GAS infections, but can also occur with Group B, Group C, and Group G streptococcal species3. Of GAS infections, ~ 50% of patients with TSS have a necrotizing soft tissue infection (NSTI)1. Bacteremia, pneumonia, and rarely pharyngitis can result in TSS. There is high mortality associated with streptococcal toxic shock ranging from 30-70% that may be related to high incidence of TSS secondary to NSTIs3.
A diffuse scarlet fever-like rash occurs only in ~ 10% of patients. The same bacterial toxins that cause toxic shock are thought to cause the rash in scarlet fever. The rash classically has a “sandpaper” texture, starts in the intertriginous areas, spreads to trunk and extremities and subsequently desquamates.
Our patient had GAS bacteremia, hypotension (BPs in the 80s/40s), evidence of renal impairment (Cr 2.1) and presence of a rash and meets criteria for toxic shock syndrome.
How do you treat it?
- Aggressive hydration and blood pressure support
- IV beta-lactam antibiotic (empiric therapy with beta-lactam + beta-lactamase inhibitor such as piperacillin-tazobactam)
- IV clindamycin 900 – 1200 mg q8hr reduces production of bacterial toxins and improves outcomes (click to learn more)
- And surgical consult for debridement if appropriate
- Consider IVIg 1 g/kg on day 1 and 0.5 mg/kg on days 2-34, though evidence for this is poor
TAKE HOME POINTS:
- Maintain a high level of suspicion for toxic shock syndrome in patients with sepsis, hypotension, and erythematous rash with suspected GPC infections
- Treat empirically with clindamycin for patients with concern for toxic shock syndrome to inhibit toxin production
- Bisno, AL & Stevens, DL. 1996. Streptococcal Infections of Skin and Soft Tissues. NEJM. 334(4): 240-245.
- Wilkins, AL, et al. 2017. Toxic shock syndrome – the seven Rs of management and treatment. Journal of Infection. 74(1): S147–S152.
- Stevens, DL. Epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock syndrome. In: UpToDate, Sexton, DJ (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017)
- Stevens, DL. Treatment of streptococcal toxic shock syndrome. In: UpToDate, Sexton, DJ (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017)
- Chu, VH. Staphylococcal toxic shock syndrome. In: UpToDate, Baron, EL (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017)