Toxic shock syndrome

What it is

Toxic shock syndrome comes in two forms, and an exotoxin is behind both.

• Staphylococcal Toxic Shock Syndrome (TSS): due to colonization with exotoxin-producing strain of Staphylococcus aureus.
• Streptococcal Toxic Shock Syndrome (STSS): due to infection with exotoxin-producing strain of group A streptococcus (GAS).

The exotoxin gives an erythematous rash, and skin desquamation follows 1-2 weeks after rash. The causes are written as toxin-producing Staphylococcus aureus and group A streptococci.

Where the toxin comes from, and who is at risk

Look for the site where the strain has taken hold:

• Small abrasions.
• Burns.
• Abscess, nasal packings and gauze-packed wounds.
• Tampon in females, or gauze packing in epistaxis.

The risk factors to explore in history are given again in the worked case: use of tampons, presence of nasal packing, skin-soft tissue infections, immunosuppression.

In the nose this is not a side note. Toxic shock syndrome is one of the late complications of nasal packing, beside pressure necrosis, septal hematomas and abscesses, and sinusitis; the immediate complication is neurogenic syncope from traumatic packing. This is why any pack left > 48 hours: give antibiotics. Anterior hemorrhage takes an anterior pack for 2 days, posterior hemorrhage a posterior pack with admission to hospital and packs in for 3-5 days, and merocel or gauze is kept max for 2 days.