Toxic shock syndrome (TSS) is a serious but rare, life-threatening disease caused by toxins produced by certain strains of staphylococcal or streptococcal bacteria. These toxins affect the entire body by causing shock (i.e., the body is unable to move enough blood to all the tissues and organs). Shock typically occurs in three stages that may progress rapidly over a 24- to 72-hour period. During the first stage, symptoms are minimal while the body attempts to compensate for the changes taking place. The second stage progresses more rapidly because the body is no longer able to compensate for the changes. Blood flow decreases to many organs, damaging them. The third stage is usually irreversible, since the heart is so extensively damaged that it cannot pump blood through the body. Organ function becomes compromised, and death may result.
Reported cases of staphylococcal toxic shock syndrome peaked in 1979 and 1980 and were mainly associated with the use of ultra-absorbent tampons by menstruating women. Since these tampons have been withdrawn from the market, menstrual-associated cases of TSS have declined.
TSS in women is associated with the prolonged use of high-absorbency tampons, menstrual sponges, diaphragms, and cervical caps that tend to trap bacteria and cause infection. Cases have also been reported following childbirth, possibly from trauma to the vaginal tissues. Toxic shock syndrome can also occur in men or women as a result of infection of wounds, insect bites, burns, bones, surgical wounds, or respiratory infections. TSS caused by group A streptococcal bacteria has a substantially higher death and complication rate than TSS caused by staphylococcal bacteria.Risk: Only women of childbearing age contract menstrual-related TSS, but men and women of all races are equally at risk for TSS associated with surgical wounds, bites, burns, and similar breaks in the skin. Risk related to age is not clear. Some studies find equal risk at all ages, whereas others find increased risk in individuals over age 60 (Sharma). Recent infection with varicella (chicken pox) appears to increase the risk of developing TSS. Incidence and Prevalence: Streptococcal toxic shock syndrome is estimated to have a rate of 1.2 to 7.3 per million individuals. The incidence of staphylococcal TSS in menstruating women is estimated at 1 per 100,000 women (Sharma). |
Source: Medical Disability Advisor
History: An individual with toxic shock syndrome presents with a sudden onset of high fever, vomiting, and watery diarrhea. These symptoms are usually accompanied by a sore throat (pharyngitis), abdominal pain, muscle pain (myalgia), joint pain (arthralgia), lightheadedness, headache, and fainting (syncope). A skin rash, inflammation of the mucus membranes of the eye (conjunctivitis), and extreme thirst may also occur. The individual may lose consciousness and depend on a family member or friend to communicate the history and symptoms. The individual may also have had a recent infection. Confusion is more common with staphylococcal toxic shock syndrome. Pain at the site of infection is the most common symptom of streptococcal toxic shock syndrome. Physical exam: The exam may reveal fever higher than 102° F (38.9° C) and low blood pressure (hypotension) accompanied by abnormalities in three or more organ systems (kidney, liver, heart, lungs, gastrointestinal, muscular, neurological, or hematological). Other findings may include red throat; swelling of the hands, feet, and ankles; and signs of wound or vaginal infections. A rash may first appear on the trunk, then spread to the arms and legs, and eventually involve the palms and soles. The skin begins to flake off 1 to 2 weeks later. Tests: Laboratory blood tests reveal an abundance of abnormalities, possibly including increased white blood cells (leukocytosis), decreased platelets (thrombocytopenia), decreased red blood cells (anemia), abnormal liver or kidney chemistries or electrolytes, abnormal blood clotting tests, urinalysis positive for bacteria or blood, and positive bacterial cultures of wound pus or vaginal fluid. Blood cultures are usually negative in staphylococcal toxic shock syndrome, since the disease is caused by the toxins produced rather than by the infection itself. Blood cultures are positive, however, in more than half of the individuals with streptococcal toxic shock syndrome.
The rapid streptococcal test can be done in 10 to 15 minutes and is positive in more than 85% of individuals with toxic shock syndrome caused by Streptococcus. In most situations, emergency treatment is started before laboratory results are available. Blood tests for viral infections and rheumatologic conditions should be negative. Electrocardiogram may be abnormal if the heart is involved. |
Source: Medical Disability Advisor
| Treatment begins immediately and usually involves rapid administration of fluids through an IV line, oxygen, heart monitoring, antibiotics, cleaning and draining of the infected area, and removal of the source of the toxin (such as a tampon). In some cases, pooled human immunoglobulin is given. Kidney, respiratory, or heart complications must be treated promptly. Surgical consultation may be needed for drainage, scraping (debridement), or amputation of a clearly infected area. |
Source: Medical Disability Advisor
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| ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.* |
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| * The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence. |
Source: ACOEM Practice Guidelines
| With proper treatment, most individuals may fully recover in 2 to 3 weeks, but in streptococcal toxic shock syndrome, death can occur in up to 30% to 70% of cases; mortality in staphylococcal toxic shock syndrome has declined to less than 2% (Sharma). If shock proceeds to its third stage, all organ systems rapidly deteriorate. Immediate, aggressive treatment yields the most favorable results. |
Source: Medical Disability Advisor
Rehabilitation therapy depends on any complications that occur from toxic shock syndrome. Because the organ most susceptible to damage during shock is the heart, a physical therapist may develop an exercise program for strengthening the heart and lungs. Toxic shock syndrome also warrants rehabilitation if the condition results in general weakness and/or affects the nervous system. Once a physician determines no contraindications for physical activity, a gradual strengthening program is initiated by the rehabilitation professional. Aerobic-type activities focus on increasing the individual's ability to work and resistance to fatigue. In the case of damage to the nervous system, issues of balance and retraining are addressed by the physical therapist.
As endurance increases without symptoms of shortness of breath, the individual can begin active light resistance training, progressing to moderate resistance exercises using free weights and/or weight machines. The frequency of the program will vary, depending on the individual's general health. If tolerated, the individual performs strengthening exercises 3 times a week and aerobic activities on the nonstrengthening days.
Balance exercises will help addressing any loss of coordination that may result from toxic shock syndrome. Balance rehabilitation varies for individuals. The intensity and progression of exercises depends on the effect they have on the body, especially the kidneys, and the individual's overall health. |
Source: Medical Disability Advisor
| Lack of blood flow can damage any organ in the body. It can cause kidney failure, brain damage, lung problems, heart damage, or loss of a limb. Release of bacterial toxins into the bloodstream may cause abnormalities in blood clotting that lead to a loss of blood supply to different parts of the body (disseminated intravascular coagulation). Lung problems may lead to extreme difficulty in breathing (adult respiratory distress syndrome, or ARDS). In severe cases, death may result. |
Source: Medical Disability Advisor
| Extended periods of weakness may prevent heavy physical work. Some mental confusion may persist for a few weeks and may diminish performance in high-stress situations. Other accommodations depend on the severity of organ damage, if any. With complete recovery, work restrictions should be minimal. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- If individual is female, does she have a history of using high-absorbency tampons, menstrual sponges, diaphragms, or cervical caps? Has she given birth recently?
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Is there a history of wound infection, insect bite, burns, recent surgery, or respiratory infection?
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Does individual have a fever higher than 102° F (38.9° C) and low blood pressure (hypotension)?
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Does individual complain of vomiting and watery diarrhea?
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Was the throat reddened and sore (pharyngitis)?
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Were there complaints of myalgia or arthralgia, and are feet and ankles swollen?
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Did individual experience lightheadedness, headache, or syncope?
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Was there a skin rash, conjunctivitis, or extreme thirst?
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Was individual confused? Complaining of pain? If so, where was the pain located?
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Did the blood reveal infection, decreased clotting ability, and/or anemia?
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Were liver and kidney functions affected?
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Did urinalysis reveal blood or bacteria?
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Was a throat culture done? Did it reveal a streptococcal infection?
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Were blood cultures negative, suggesting staphylococcal TSS, or were they positive, suggesting streptococcal TSS?
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What organisms, if any, did wound or vaginal cultures reveal?
Regarding treatment:
- Was treatment received quickly?
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Did individual receive intravenous fluids and antibiotic therapy? Was the source of the toxin removed?
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How did individual respond to treatment?
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Did individual receive surgical consultation? If so, was surgical intervention warranted?
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Has there been kidney, lung, or heart involvement? If so, was consultation from appropriate specialists received (nephrologist, pulmonologist, cardiologist)? Was the damage to the organ(s) temporary and reversible or permanent and irreversible?
Regarding prognosis:
- Did adequate time elapse for recovery (2 to 3 weeks)?
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Based on the type of infection, what was the expected outcome?
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Did individual suffer any complications, such as organ dysfunction, gangrene, or coagulopathy that could affect recovery and prognosis?
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Was surgical amputation of a limb performed to treat gangrene?
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Would individual benefit from psychiatric counseling to recover from the trauma of the illness?
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Source: Medical Disability Advisor
| CitedSharma, Sat. "Toxic Shock Syndrome." eMedicine. Eds. Cory Franklin, et al. 22 Jan. 2003. Medscape. 16 Oct. 2004 <http://emedicine.com/med/topic2292.htm>.Marx, J. A., et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis: Mosby, Inc., 2002. |
Source: Medical Disability Advisor
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