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Toxic Shock Syndrome Made Extremely Easy!
- 1. Bacterial Exanthems Part I: Toxic Shock Syndrome:
- 2. Introduction: ā¢ Exanthem is the name given to a widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache. ā¢ It is usually caused by an infectious condition and represents either a reaction to a toxin produced by the organism, damage to the skin by the organism, or an immune response.
- 3. Classification of Bacterial Exanthems: ā¢ Staphylococcal toxin infections: ā Toxic shock syndrome (TSS) ā Staphylococcal scalded skin syndrome (SSSS) ā¢ Streptococcal toxin infections: ā Scarlet fever ā Streptococcal toxic shock-like syndrome (STSS) Exanthem of Unknown Etiology: ā¢ Kawaski Disease
- 4. Toxic Shock Syndrome (TSS):
- 5. Definition and nomenclature: Serious lifeāthreatening illness characterized by fever, acute erythema followed by desquamation, circulatory shock and multisystem disease mediated by one or more bacterial toxins elaborated by Staphylococcus aureus or Streptococcus pyogenes. Synonyms: ā¢ Staphylococcal TSS ā¢ Streptococcal TSS
- 6. Causative organisms: ā¢ Staphylococcus aureus. ā¢ Streptococcus pyogenes
- 8. Introduction and general description: ā¢ Historically most cases were reported shortly after the introduction of superāabsorbent tampons in the 1970s. ā¢ Many menstruating women using these highly absorbent tampons presented acutely unwell with fever, low blood pressure and multi-organ failure leading to a death. ā¢ This particular type of tampon is no longer manufactured and the number of cases has consequently declined dramatically.
- 9. Epidemiology: Incidence and prevalence ā¢ Approximately 1ā17/100 000 tampon users per annum. Age ā¢ Any age but is more common at the extremes of age and in menstruating women (15ā40 years). Sex ā¢ Historically, it was more common in females. Ethnicity ā¢ Black women (Aged 13-40 years) in the USA had lower antibody titres to TSS toxin 1 (TSSā1) than white or Hispanic women, suggesting the former are more at risk of menstrual TSS
- 10. An awareness poster from 1985
- 11. Associated diseases: ā¢ Recent chickenpox infection, ā¢ Cellulitis ā¢ Necrotizing fasciitis, ā¢ Underlying HIV or ā¢ Internal malignancy, ā¢ Alcohol misuse and ā¢ Diabetes
- 12. Pathophysiology: (a)Predisposing factors: ā¢ Staphylococcal infection of any severity, at any site, at any age and in either sex may cause TSS. ā¢ TSS due to Tampons was the result of introduction of the Staphylococci by hand or from perineal skin. Appropriate conditions for Satphylococcal growth were provided in the medium of the menstrual blood, facilitated in some way by the tampon. ā¢ Postpartum Women are also at risk in addition to using internal barrier type contraception such as the diaphragm.
- 13. Pathophysiology Contd: ā¢ Toxic shock syndrome toxin 1 (also called staphylococcal enterotoxin F / pyrogenic exotoxin C or TSS-1 toxin), is produced by S. aureus and is believed to be the main bacterial mediator of the disease. ā¢ More recently, staphylococcal enterotoxin B was also identified. ā¢ TSS-1 Toxin is able to stimulate Tālymphocyte proliferation in a nonāantigenāspecific manner. ā¢ This results in fever, inflammation and shock. TSS Due to Streptococcus: ā¢ May be cause by a re-emergent scarlet fever toxin A produced by Streptococcus pyogenes.
- 14. Pathology: ā¢ No specific histological features. ā¢ A perivascular mononuclear cell infiltrate and papillary oedema may occur in the dermis. ā¢ In cases with blister formation the split is subepidermal.
- 15. Clinical features: (a) History In menstrual TSS, women are usually about 5 days into their menstrual bleeding when they present with malaise and fever. (b) Presentation ā¢ Fever ā„ 38.9ā°C ā¢ Rash: ā May be the presenting feature or appear within the first day. ā Appears as widespread macular erythema but scarlintiform and papulopustular eruptions also noted. Clears within 3 days. ā Marked edema of hands and feet with blistering. ā¢ Circulatory Shock: ā Is often rapid in onset and severity, ā Does not respond to intravenous fluid replacement ā Acute renal impairment frequently coexists. ā¢ Multi-system Involvement: 3 or more of the following: ā Gastrointestinal: vomiting or diarrhea at onset of disease. ā Muscular: severe myalgia or creatine phosphokinase of at least twice the upper limit of normal for the laboratory ā Mucus Membrane: vaginal, bladder, oral or conjunctival hyperemia or ulceration ā Renal: Blood Urea Nitrogen or creatinine at least twice the upper limit OR Pyuria in the absence of Urinary tract infection ā Hepatic: Total bilirubin, ALT, AST twice the upper limit of normal. ā Hematologic: Thrombocytopenia (ā¤100,000/mm3) causes retiform purpura in the peripheries. ā Central Nervous System: disorientation or altered consciousness without focal neurological signs when fever and hypotension are absent.
- 16. Late Clinical Features: ā¢ Towards the end of the second week, majority of patients develop a widespread, itchy, maculopapular sometimes urticarial rash. ā¢ Desquamation is highly characteristic occurring 10ā21 days after onset. May be confined to the fingertips, palmoplantar skin or may be generalized. (See picture below) ā¢ Reversible patchy alopecia or telogen effluvium ā¢ Transverse ridging and partial loss of nails.
- 17. Figure 1: Diffuse erythroderma, purpura, and petechiae with severe generalized edema (A). Erythroderma, livid swelling, confluent bullae, and diffuse desquamation of the right leg (B, C).
- 19. Differential diagnosis ā¢ Septic shock ā¢ Kawasaki disease: differentiated by prolonged fever, cardiac involvement, generalized lymphadenopathy and absence of peripheral shock. ā¢ Staphylococcal Scarlatina ā¢ Ehrlichosis ā¢ Clostridium sordellii infection: The disease resembles TSS syndrome except that there is no associated rash; it may follow postpartum infections
- 20. Complications and coāmorbidities: Toxic shock syndrome results in multiorgan failure manifest as: ā Adult respiratory distress syndrome, ā Acute or chronic renal failure ā Disseminated intravascular coagulation.
- 21. Disease course and prognosis: ā¢ Treatment in a high dependency unit with prompt use of appropriate intravenous antibiotics, most patients recover over about 3 weeks; ā¢ Mortality rate remains at about 7%.
- 22. Investigations: ā¢ Confirmation through microbiological cultures. Microbiological swabs from wounds and from the vagina of menstruating or postpartum females should also be taken. ā¢ Several sets of blood cultures should be taken. ā¢ Routine biochemistry: ā Raised creatinine which frequently precedes hypotension. ā Raised creatine phosphokinase ā Increased total bilirubin, ALT and AST ā¢ Complete Blood Count: ā Thrombocytopenia
- 23. Management: ā¢ Tampons if present should be removed and infected wounds debrided. ā¢ Intensive general supportive measures are essential such as fluid resuscitation and ventilatory support commenced. ā¢ Patients may require noradrenaline circulatory support and dialysis. ā¢ Lowādose systemic corticosteroids reduced the duration and dose of vasopressor agents in septic shock and ameliorates septic shock but does not reduce mortality at day 28. ā¢ Synthetic human monoclonal antibodies: against staphylococcal enterotoxin B are protective against TSS in mice and enhance survival. ā¢ Intravenous clindamycin (600ā900 mg three times daily) should be given as first line treatment as this is highly effective against most strains of S. aureus and S. pyogenes, and is known to reduce toxin production. ā¢ Some physicians give additional benzylpenicillin sodium (penicillin G, 2.4ā4.8 g daily in four divided doses) or vancomycin (1ā1.5 g every 12 h) to ensure both staphylococcal and streptococcal organisms are adequately covered. ā¢ Intravenous antibiotics are usually continued for up to 1ā2 weeks depending on the clinical response.
- 25. Future topics to be discussed: ā¢ Scarlet Fever ā¢ Staphylococcal scalded skin syndrome ā¢ Kawaski disease. Previously Discussed Topics: ā¢ Warts: Common warts, anogenital warts, warts in immunocompromised patients, epidermodysplasia verruciformis. ā¢ Viral Exanthems: Measles, Rubella, Erythema Infectiosum, Roseola Infantum, Cytomegalovirus, Infectious mononucleosis.