A Health Professional’s Guide

Table 1

Toxic Shock Syndrome: Case Definition*

1) Fever:

temperature ≥ 38.9oC

2) Rash:

diffuse macular erythroderma (“sunburn”)

3) Hypotension:

systolic blood pressure ≤ 90 mm Hg (adults) or ≤ 5th percentile for age (children under 16 years of age), or orthostatic hypotension, dizziness or syncope

4) Multisystem dysfunction:
(at least three)

a. Gastrointestinal: vomiting or diarrhoea at onset of illness
b. Muscular: severe myalgias, or serum creatine phosphokinase level (CPK) ≥ twice the upper limit of normal
c. Mucous membranes: vaginal, oropharyngeal, or conjunctival hyperemia
d. Renal: blood urea nitrogen (BUN) or creatinine ≥ twice the upper limit of normal, or pyuria ( ≥ 5 leuckocytes per high-power field), in the absence of urinary tract infection
e. Hepatic: total serum bilirubin or transaminase level ≥ twice the upper limit of normal
f. Hematologic: platelets ≤ 100,000 per L
g. Central nervous system: disorientation or alteration in consciousness but no focal neurological signs at a time when fever and hypotension are absent

5) Desquamation:

1 to 2 weeks after the onset of illness (typically palms and soles)

6) Evidence against an alternative diagnosis:

If obtained: negative cultures of blood, throat, or cerebrospinal fluid^; absence of a rise in antibody titres to the agents of, leptospirosis, measles or Rocky Mountain spotted fever.

Source: Reingold AL, Hargrett NT, et al. Toxic shock syndrome surveillance in the United States, 1980 to 1981. Ann Intern Med 1982; 96(Part 2): 875-880.

* “Confirmed” case meets all six criteria; “probable” case meets 5 of the 6.

^ Blood culture may be positive for S. aureus.

Table 2

Toxic Shock Syndrome: Clinical Settings*

Menstrual TSS

1) Tampon-associated^
2) Not tampon-associated

Non-Menstrual TSS

1) TSS Related to the Female Genitourinary Tract

  • associated with barrier contraceptive use (diaphragm, contraceptive sponge)
  • occurring in the puerperium
  • following non-obstetric gynaecological surgery
  • associated with septic abortion

2) TSS Related to Skin or Soft Tissue Infections

  • primary staphylococcal infections (folliculitis, cellulitis, carbuncle, muscle abscess)
  • staphylococcal superinfections of pre-existing lesions (burns, insect bites, varicella/zoster infections, surgical wounds˚

3) TSS Related to Respiratory Tract Infections

  • upper respiratory tract focus (sinusitis, pharyngitis, laryngotracheitis, odontogenic infection)
  • lower respiratory tract focus (staphylococcal pneumonia)

4) TSS Related to Skeletal Infections

  • osteomyelitis
  • septic arthritis

* Menstrual and non-menstrual cases occur with approximately equal frequencies and are clinically identical. The mortality rate of non-menstrual illness is substantially higher, likely due to delayed diagnosis of non-menstrual cases.

^ The risk of TSS is particularly high in seronegative women with a prior history of TSS. Such women should avoid use of tampons or barrier contraceptives until such time as seroconversion is documented.

˚ The time interval to onset of postoperative TSS ranges from hours to weeks after the surgical procedure. The risk of TSS is particularly great following rhinoplasty or nasal septoplasty, in which settings it has been estimated at 16.5 cases per 100,000 population at risk.

Table 3

Illnesses that may resemble Toxic Shock Syndrome

  • Severe group A streptococcal infections (scarlet fever, necrotising fasciitis, toxic shock-like syndrome)*
  • Kawasaki syndrome^
  • Staphylococcal scalded skin syndrome˚
  • Rocky Mountain spotted fever
  • Leptospirosis
  • Meningococcemia
  • Gram-negative sepsis
  • Exanthematous viral syndromes (e.g., rubeola, adenoviral infection, certain enteroviral infections, dengue)

* Streptococcal toxic shock-like syndrome may be clinically indistinguishable from TSS. Extensive soft tissue destruction and exudativepharyngitis are suggestive of a streptococcal etiology

^Rare above the age of 4 years. Presents subacutely rather than acutely. Thrombocytosis (rather than thrombocytopenia) is common.

˚Rare above the age of 5 years. The skin may be diffusely tender, and sloughs early on. Systemic toxicity is rare.


Bergdoll MS, Crass BA, Reiser RF, et al. An enterotoxin-like protein in Staphylococcus aureus strains from patients with toxic shock syndrome. Ann Intern Med 1982; 96 (Part2): 969-71.

Chesney PJ, Bergdoll MSToxic Shock Syndrome, Boca Raton: CRC Press, 1991.

Deresiewicz RL. Staphylococcal toxic shock syndrome. In: Leung DYM, Huber BT, Schlievert PM, eds. Superantigens: Molecular biology, immunology, and relevance to human disease. New York: Marcel Dekker, 1997: 435-79.

Marrack P, Kappler J. The staphylococcal enterotoxins and their relatives. Science 1990; 248:705-11.

Parsonnet J. Nonmenstrual toxic shock syndrome: new insights into diagnosis, pathogenesis, and treatment. In: Remington JS, Swartz MN, eds. Current Clinical Topics in Infectious Diseases. Vol.16. Cambridge, MA: Blackwell Science, 1996:1-20.

Todd J, Fishaut M. Toxic-shock syndrome associated with phage-group-1 staphylococci. Lancet 1978;2:1116-8.