Thank you Bridget, Lily, and Kresh for presenting a case of a young man with hypertension who presented with acute onset, bilateral testicular swelling, and was ultimately found to have streptococcal toxic shock syndrome and stress cardiomyopathy!
- Consider toxic shock syndrome (TSS) when patients present with significant skin/soft tissue pain out of proportion to examination.
- For Streptococcal toxic shock syndrome, strep pyogenes (Group A strep) is the most frequent organism.
- Renal failure occurs in most all patients with TSS, resulting from significant shock, myoglobinuria, and hemoglobinuria.
Streptococcal Toxic Shock Syndrome (TSS)
- most frequently occurs in the setting infection due to group A Streptococcus (GAS; Streptococcus pyogene)
- Pathophysiology: Superantigens!
- GAS is an aerobic gram-positive coccus that releases exotosins that act as a superantigen, that activates the immune system by bypassing the usual antigen-mediated immune response sequence!
- Thank you Amy Berger (Molecular Medicine fellow) for providing us with this diagram below.
- How to diagnose?
- Consider the clinical history: history of recent trauma, severe, pain, fever
- Clinical guideline for Group A Strep TSS: – Isolation of GAS from normally sterile site (blood, CSF, pleural fluid, peritoneal fluid, tissue biopsy, surgical wound) – Hypotension PLUS 2 or more of the following: – Renal dysfunction – Coagulopathy – Liver dysfunction – ARDS – Erythematous macular rash – Soft tissue necrosis
- Clinical Manifestations
- Typically presents with pain that precedes physical findings of infection. Clinical signs of SSTI consist of localized swelling and erythema followed by ecchymoses, with progression to necrotizing fasciitis or myositis
- Complications include bacteremia, renal failure, ARDS, DIC, Waterhouse-Friderichsen Syndrome
- Renal failure occurs in nearly all patients within 48-72 hrs. Hypotension, myoglobinuria, and hemoglobinuria (due to toxin-induced hemolysis) can contribute.
- Treatment of TSS
- Resuscitation and source control (surgical debridement, vaginal examination in all women)
- Antibiotics to reduce organism load
- Clindamycin: protein synthesis inhibitor to decrease toxin production
- IVIG: Toxin neutralization, non-specific anti-inflammatory effects
- Check out our prior pearls: