Toxic shock syndrome (TSS) is a severe acute multiple organ lesion caused by exotoxins of Staphylococcus aureus or pyogenic streptococcus. It is manifested by a sudden increase in temperature to 38.9 ° C or more, a drop in blood pressure, erythematous skin rashes followed by peeling, profuse diarrhea, vomiting, signs of damage to various organs and systems. The diagnosis of TSS is established on the basis of the clinical picture, physical examination data, laboratory, including bacteriological, analyses. Treatment involves the rehabilitation of the bacterial focus, the appointment of antibiotics, infusion and symptomatic therapy.
A48.3 Toxic shock syndrome
Toxic shock syndrome was first diagnosed in 1978 in seven children with staphylococcal infection. Specialists in the field of gynecology encountered it two years later, noting the link between the development of the syndrome in young women with the use of superabsorbent hygienic tampons during menstruation. The absolute majority of patients are women aged 17-30 years. Approximately half of them have the development of the syndrome associated with menstruation. In a quarter of cases of non—menstrual TSS, the disease occurs in the postpartum period in carriers of Staphylococcus aureus, in 75% – as a result of other causes (skin and subcutaneous infection, tamponing operations, etc.).
Toxic shock syndrome is caused by exotoxin-producing microorganisms that have a systemic effect on various organs and tissues — Staphylococcus aureus (Staphylococcus aureus) and pyogenic beta-hemolytic streptococcus group A (Streptococcus pyogenes). In most cases, the disease does not occur at the time of primary infection with bacteria, but against the background of the carrier of infectious pathogens under the influence of the following predisposing factors:
- The use of tampons. The probability of developing TSS increases with the use of hygiene products with increased adsorbing properties and violation of the recommended frequency of their replacement.
- The use of intravaginal contraceptives. The presence of diaphragms, sponges, caps in the vagina creates favorable conditions for the reproduction of microorganisms.
- Violation of the integrity of the mucous membranes. With injuries of the genitals, the presence in the uterus of remnants of placental tissue, fetal membranes, blood after childbirth and gynecological operations, optimal conditions arise for bacterial contamination and penetration of microorganisms or their toxins into the blood.
Non-menstrual toxic shock syndrome can complicate surgical procedures in which a blood-accumulating dressing is used (operations on the nasal cavity using turundum, wound tamponing, etc.), and traumatic skin injuries. The combination of these factors with viral diseases (chickenpox, flu), taking immunosuppressive drugs increases the risk of developing toxemia and bacteremia.
A key role in the development of toxic shock syndrome is played by mechanical and chemical influences that promote the reproduction of bacteria and affect the permeability of tissues. The starting point is the penetration into the blood of significant amounts of specific toxins (TSST) and their interaction with T-lymphocytes. As a result, cytokines are massively released, causing a multi-organ toxic reaction. Vessels expand and the permeability of their walls increases, which leads to the movement of blood plasma and serum proteins into the extravascular space. At the same time, there is a sharp drop in pressure, swelling occurs, coagulation is disrupted, and the temperature rises. Under the influence of mediated immune reactions and the direct action of toxins, the skin, liver parenchyma, lungs and other organs are affected.
Symptoms of toxic shock syndrome
In menstruating women using tampons, signs of TSS appear on the 3rd-5th day of menstruation. With toxic shock syndrome, which complicated childbirth or gynecological operations, pathology manifests itself in the first 2 days of the postpartum or postoperative period. As a rule, the disease occurs acutely. In rare cases, there is a prodrome in the form of general malaise, nausea, headache and muscle pain. The first sign of TSS is severe chills with an increase in temperature to 39-40 ° C, after which a complete clinical picture unfolds within 1-4 days.
Almost all patients experience muscle weakness and diffuse muscle pain, especially in the muscles of the proximal extremities, abdominal and back. Joint pain is often a concern. More than 90% of patients report persistent vomiting and profuse watery diarrhea, a meager amount of urine. There are sore throats, paresthesia, headache, photophobia, dizziness and fainting against the background of falling blood pressure. In some cases, cough, painful sensations when swallowing are bothering. In the acute stage, lasting from 24 to 48 hours, the patient looks inhibited and disoriented.
A specific manifestation of the syndrome is skin rashes in the form of diffuse redness, which resembles a sunburn and begins to gradually fade during the first 3 days. Subsequently, there is a rough peeling of the skin, especially noticeable on the soles and palms. In some women, redness has the character of spots of various sizes, which are joined by small nodular rashes or spot petechial hemorrhages. Almost a quarter of patients on the 5th-10th day have severe itching on the background of spotty-nodular rash. Almost 100% of patients by the end of 1-2 weeks have a shallow generalized scaly exfoliation of the skin epithelium with more pronounced lamellar peeling of the palms, soles, fingers and toes. Half of the patients who underwent TSS, by the end of the 2-3 month, noted hair loss and nail convergence.
Conjunctival hyperemia, redness of the posterior pharyngeal wall and oral mucosa, crimson-red color of the tongue are detected in almost 3/4 of cases. Every third menstruating woman with TSS is concerned about soreness and swelling in the area of the labia majora and labia minora. With a severe course of the syndrome, there are signs of toxic damage to the liver, kidneys, respiratory system with transient jaundice of the skin, abdominal pain, lower back, right hypochondrium, turbidity of urine, shortness of breath, etc.
In addition to clinically expressed toxic shock syndrome, there is its erased form (with primary manifestation or repeated episode): the patient has fever, chills, moderate muscle pain, nausea, vomiting, diarrhea, sore throat. However, blood pressure does not decrease, and the pathological condition is resolved without treatment.
In the severe course of the syndrome, a toxic shock is observed, leading to a violation of microcirculation and aggravating the lesion of parenchymal organs. There is respiratory failure with shortness of breath and worsening of blood oxygenation, DIC syndrome with thromboembolism and profuse bleeding, heart rhythm is disturbed, as a result of acute tubular necrosis, the kidneys fail. Patients with streptococcal TSS develop bactriemia and necrotizing fasciitis in more than 50% of cases. In the long-term period, temporary loss of nails and hair, neurological disorders (paresthesia, memory disorders, increased fatigue) are possible.
Taking into account the multi-organ nature of the disease, in order to make a diagnosis, it is necessary to evaluate both local changes on the part of female organs and signs of violations of other systems. The comprehensive examination includes:
- Gynecologist’s examination. Swelling and hyperemia of the genitals are revealed, in some cases — scanty purulent discharge from the cervical canal. Palpation can determine soreness in the appendages.
- Physical examination. In 100% of cases, there is an increase in temperature of more than 38.9 ° C and a drop in systolic pressure below 90 mmHg (usually with an orthostatic decrease of 15 mmHg).
- General clinical tests. UAC is characterized by leukocytosis with high neutrophilosis, a shift of the leukocyte formula to the left, thrombocytopenia, anemia, increased ESR. In the general analysis of urine, an abnormal urinary sediment with leached erythrocytes and sterile pyuria is determined.
- Biochemical blood analysis. With impaired liver function, bilirubin levels and transferase activity increase (detected in almost half of the patients), with renal insufficiency, azotemia, creatininemia occur, with muscle damage — an increased content of CK. Prothrombin time and partial thromboplastin time increase in the coagulogram, fibrin degradation products are determined. A blood test for electrolytes reveals metabolic acidosis, a decrease in the level of calcium, phosphorus, sodium, potassium.
- Methods for determining the pathogen. To identify an infectious agent, a back-seeding of a smear from the genitals with an antibioticogram and a blood culture (indicated if streptococcal TSS is suspected) are used. Serological studies make it possible to assess the indicators of the immune system, exclude infectious diseases with a similar clinical picture.
- Instrumental diagnostics. An ECG allows timely detection of cardiac arrhythmias. Fluorography or radiography of the chest is recommended for assessing the condition of the lungs.
TS syndrome is differentiated from sepsis and infectious diseases (measles, scarlet fever, leptospirosis, hepatitis B, Rocky Mountain spotted fever, typhoid fever, meningococcemia, viral exanthemums). The patient is advised by an anesthesiologist-resuscitator, infectious disease specialist, cardiologist, surgeon, urologist, dermatologist, pulmonologist, neurologist.
Treatment of toxic shock syndrome
When choosing a treatment regimen for toxic shock syndrome, it is important to consider the impact on the factors that caused the disease and measures to stabilize the functions of the affected systems. The patient is shown:
- Sanitation of the bacterial focus. First of all, remove the tampon, diaphragm, cap (if any) and wash the vagina with a sterile solution. If bacterial seeded wounds are detected, tissue excision with necrosis sites is possible.
- Antibiotic therapy. The choice of the drug is based on the results of determining sensitivity to antimicrobial agents. Before receiving such data, empirical therapy is prescribed, taking into account the probable pathogen and its possible antibiotic resistance. The course is up to 10 days.
- Infusion therapy. The key element of treatment is the restoration of intravascular fluid volume and stabilization of hemodynamic parameters. Depending on the nature of the disorders, the patient is injected with crystalloid solutions, electrolytes, freshly frozen blood plasma, platelet mass, etc.
- Vasopressors. If the correction of the volume of intravascular fluid does not allow to normalize blood pressure, drugs with a pressor effect are administered.
With severe organ failure, the patient may be prescribed hemodialysis (with acute renal failure), artificial ventilation with positive exhalation pressure (with respiratory distress syndrome). A number of authors note a faster recovery with the appointment of corticosteroids and immunoglobulins.
Prognosis and prevention
In most cases, thanks to the achievements of modern gynecology, timely diagnosis and treatment, patients with staphylococcal TSS recover in 1-2 weeks, while mortality at the present stage is 2.6%. Temperature and blood pressure normalize within 2 days from the moment of hospitalization, and laboratory parameters – on the 7th- 14th day. The level of red blood cells is restored after 4-6 weeks. With streptococcal toxic shock, mortality still remains high and reaches 50%. For the prevention of TSS, it is important to follow the recommendations on the use of tampons and examination protocols before childbirth and gynecological operations for the timely detection of pathogens.