Staphylococcal Toxic Shock Syndrome

Streptococcal Toxic Shock Syndrome

Clinical Findings

•Fever: temperature ≥38.9°C (102°F)

•Rash: diffuse macular erythroderma

•Desquamation: 1–2 weeks after onset (especially palms, soles, fingers, toes)

•Hypotension: systolic blood pressure ≤90 for adults and <5th percentile for age for children <16 years, or orthostatic changes (blood pressure decline, syncope, dizziness)

•Involvement of 3 or more of the following systems:

– Gastrointestinal: vomiting or diarrhea

– Muscular: severe myalgia or creatine kinase greater than twice the upper limit of reference

– Mucous membrane hyperemia

– Renal: sterile pyuria; blood urea nitrogen or creatinine greater than twice the upper limit of reference

– Hepatic: total bilirubin, aspartate aminotransferase, or alanine aminotransferase greater than twice the upper limit of reference

– Hematologic: platelet count ≤100,000/mm³

– Central nervous system: disorientation, altered consciousness without focal neurologic signs

I. Isolation of group A streptococcus

A. From a normally sterile site (eg, blood, cerebrospinal fluid, peritoneal fluid, joint, pleural or pericardial fluid)

B. From a nonsterile site (eg, throat, sputum, vagina, open surgical wound, superficial skin lesion)

II. Clinical signs of severity

A. Hypotension: systolic blood pressure ≤90 for adults and <5th percentile for age for children <16 years of age

and

B. Two or more of the following signs:

•Renal impairment: creatinine concentration ≥2 mg/dL for adults or at least 2 times the upper limit of reference for age

•Coagulopathy: platelet count ≤100,000/mm³ or disseminated intravascular coagulation

•Hepatic involvement: total bilirubin, aspartate aminotransferase, or alanine aminotransferase at least twice the upper limit of reference for age

•Adult respiratory distress syndrome

•A generalized erythematous macular rash that may desquamate

•Soft tissue necrosis, including necrotizing fasciitis or myositis, or gangrene

Laboratory Criteria

•Negative results on the following tests if performed:

– Blood, throat, or cerebrospinal fluid cultures; however, blood culture result may be positive in select cases for Staphylococcus aureus.

– Serologic tests for Rocky Mountain spotted fever, leptospirosis, or measles.

Laboratory Criteria

•As previously noted.

Case Classification

•Probable: A case meets laboratory criteria and 4 of 5 clinical findings are present.

•Confirmed: A case meets laboratory criteria and all 5 clinical findings, including desquamation (unless the patient dies before desquamation appears).

Case Classification

•Confirmed: Case fulfills criteria IA, IIA, and IIB.

•Probable: Case fulfills criteria IB, IIA, and IIB (if no other cause for the illness is identified).