Streptococcal toxic shock syndrome

Streptococcal toxic shock syndrome (Streptococcal TSS) usually begins as a skin infection. Fever, rash, and shock follow. Streptococcal TSS, compared to staphylococcal TSS, causes more ARDS and less cutaneous rash. Mortality rates are higher (20% to 60% vs. <3% for staphylococcal TSS).

CASES/YEAR
1,680 (US); 33,600 (Global)
CATEGORY
AGENT TYPE
Bacteria
OTHER NAMES
Streptococcal TSS; STSS;
ACUITY
Acute-Severe
INCUBATION
Probably a few days;
INITIAL SYMPTOMS
Skin infection, fever, rash, and shock;
PRECAUTIONS
Standard; "Droplet Precautions for the first 24 hours after implementation of antibiotic therapy if Group A streptococcus is a likely etiology." [CDC 2007 Guideline for Isolation Precautions]
COMMENTS
The CDC case definition includes hypotension and multi-organ involvement with renal injury; platelets <100,000/mm3; liver injury; acute respiratory distress syndrome (ARDS); erythematous macular rash; and necrotizing fasciitis. The erythematous rash followed by desquamation is not as common as it is in Staph toxic shock syndrome. Outbreaks of streptococcal TSS have been reported. [ID, p. 1580-1] Complications include hypotension, renal impairment, thrombocytopenia, disseminated intravascular coagulation, abnormal liver function tests, necrotizing fasciitis, and ARDS. "TSS may occur with either systemic or focal (throat, skin, lung sites) group A streptococcal infections, and mortality rates are as high as 35% -40%" [CCDM, p. 583-4] The syndrome usually occurs in immunocompetent children or adults with a streptococcal skin infection. Streptococcal TSS, compared to staphylococcal TSS, causes more ARDS and less cutaneous rash; mortality rates are higher--20% to 60% compared to <3% for staphylococcal TSS. [Merck Manual, p. 1608] Severe pain and tissue necrosis are rare in Staph TSS, but common in Strept TSS. Bacteremia, which occurs in about 60% of Strept TSS cases, is uncommon in Staph TSS. Mortality rates are <3% (Staph) and 30-60% (Strept). [PPID, Table 57.4] The three phases are: 1.) flu-like syndrome with vomiting and diarrhea; 2.) tachycardia, tachypnea, persistent fever, and in some patients, increasing pain at the site of the primary skin infection; and 3.) shock and organ failure. Other than the skin, the infection may originate from pneumonia, meningitis, peritonitis, myocarditis, and infections of a joint, an eye, or the uterus. Necrotizing fasciitis is often not diagnosed until after the onset of hypotension, and it may progress rapidly--from red skin to purple bullae in 24 hours and from hospitalization to death in 24-48 hours. Fever and severe pain are the first signs of necrotizing fasciitis. More than 1/2 of patients develop acute renal failure. Thrombocytopenia is the earliest sign of disseminated coagulopathy. [PPID, p. 2457-8] Hemoglobinuria and elevated creatinine at the time of admission are evidence of renal involvement. Over one half of patients have confusion, and some progress to coma. [Guerrant, p. 205]
DIAGNOSTIC
Clinical; Culture;
SCOPE
Global
SIGNS & SYMPTOMS
  • >fever
  • >myalgia
  • E pharyngitis
  • G diarrhea
  • G liver function test, abnormal
  • G nausea, vomiting
  • H hemolysis
  • H leukocytosis
  • H thrombocytopenia
  • N confusion, delirium
  • S rash (exanthem)
  • S skin blister or vesicles
  • X lung infiltrates
  • *acute renal failure
  • *ARDS
  • *bleeding tendency
  • *rhabdomyolysis
  • *sepsis
  • *shock
  • *stupor, coma
ANTIMICROBIC

Yes

VACCINE

No

ENTRY
Skin or Mucous Membranes (Includes Conjunctiva)
SOURCE
Person-to-Person
RESERVOIR
Human
RISK FACTORS
REFERENCES FOR CASES/YEAR
1. (US) Published in MMWR 2011 = 168; Use correction factor of 10 for reported diseases: 168 X 10 = 1680;
2. (Global) Estimate global rate at 20 X US rate = 33,600;