Toxic shock syndrome is a severe acute multi-organ lesion caused by exotoxins of Staphylococcus aureus or pyogenic Streptococcus. Manifested by a sudden increase in temperature to 38.9 ° C or more, a drop in blood pressure, erythematous skin rash, followed by desquamation, profuse diarrhea, vomiting, signs of damage to various organs and systems. The diagnosis of TSS is established on the basis of the clinical picture, the data of the physical examination, laboratory, including bacteriological, analyzes. The treatment involves the rehabilitation of a bacterial focus, the prescription of antibiotics, infusion and symptomatic therapy.
Toxic shock syndrome (TSS) was first diagnosed in 1978 in seven children with a staphylococcal infection. Specialists in the field of gynecology came across it two years later, noting the relationship of the development of the syndrome in young women with the use of superabsorbing hygienic tampons during menstruation. The absolute majority of patients are women aged 17-30. Approximately half of them develop the syndrome associated with menstruation. In a quarter of cases of nonmenstrual 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, previous operations with plugging, etc.).
Causes of TSS
The syndrome of toxic shock cause exotoxin-producing microorganisms that have a systemic effect on different organs and tissues – Staphylococcus aureus and pyogenic β-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 carriage of infectious pathogens when exposed to the following predisposing factors:
- The use of tampons. The likelihood of developing TSS increases with the use of hygienic means with increased adsorbing properties and a violation of the recommended frequency of their replacement.
- Use of intravaginal contraceptives. The presence in the vagina of the diaphragms, sponges, caps creates favorable conditions for the reproduction of microorganisms.
- Violation of the integrity of the mucous membranes. With injuries of the genital organs, the presence in the uterus of residues of placental tissue, fetal membranes, blood after childbirth and gynecological operations, optimal conditions arise for bacterial contamination and the penetration of microorganisms or their toxins into the blood.
Nemenstrual toxic shock syndrome can complicate surgical procedures that use a dressing material that accumulates blood (operations on the nasal cavity with the use of turunds, plugging wounds, etc.), and traumatic skin damage. The combination of these factors with viral diseases (chickenpox, influenza), taking immunosuppressive drugs increases the risk of toxemia and bacteremia.
The key role in the development of toxic shock syndrome is played by mechanical and chemical effects that promote the growth of bacteria and affect tissue permeability. 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. The vessels expand and the permeability of their walls increases, which leads to the movement of blood plasma and serum proteins into the extravascular space. In this case, there is a sharp drop in pressure, edema occurs, coagulation is disturbed, and the temperature rises. Under the influence of mediated immune reactions and the direct action of toxins, the skin, the parenchyma of the liver, lungs and other organs are affected.
Symptoms of TSS
In menstruating women using tampons, signs of TSS appear on the 3-5th day of menstruation. In the syndrome of toxic shock, complicated labor or gynecological surgery, the pathology appears 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 a strong chill with a rise in temperature of up to 39-40 ° C, after which the full clinical picture unfolds within 1-4 days.
Almost all patients have muscle weakness and diffuse pain in the muscles, especially in the muscles of the proximal limbs, abdominals and back. Often concerned about pain in the joints. More than 90% of cases show persistent vomiting and profuse watery diarrhea, a scant amount of urine. There is sore throat, paresthesia, headache, photophobia, dizziness and fainting amid falling BP. In some cases, worried about coughing, pain when swallowing. In the acute stage, lasting from 24 to 48 hours, the patient looks inhibited and disoriented.
A specific manifestation of the syndrome is a skin rash in the form of diffuse redness, which resembles a sunburn and begins to fade over the first 3 days. Subsequently, there is a rough peeling of the skin, especially noticeable on the soles and palms. In some women, the redness has the character of spots of various sizes, which are joined by small nodular eruptions or petechial punctate hemorrhages. Almost a quarter of the patients on the 5th-10th day have severe itching on the background of a mottled nodular rash. In almost 100% of patients, by the end of week 1–2, there was a shallow generalized scaly exfoliation of the skin epithelium with a more pronounced lamellar peeling of the palms, soles, fingers and toes. Half of the patients who have had TSS, by the end of the 2-3rd month notes hair loss and toe nails.
In almost 3/4 cases, conjunctival hyperemia, redness of the posterior pharyngeal wall and oral mucosa, and raspberry-red color of the tongue are detected. Every third menstruating woman with TSS is worried about pain and swelling in the region of the labia minora and labia. In severe syndrome, there are signs of toxic damage to the liver, kidneys, respiratory system with transient yellowness of the skin, pain in the abdomen, lower back, right hypochondrium, turbidity of the urine, shortness of breath, etc.
In addition to the clinically expressed syndrome of toxic shock, there is its erased form (with the initial manifestation or repeated episode): the patient has a fever, chills, moderate muscle pain, nausea, vomiting, diarrhea, sore throat. However, blood pressure is not reduced, and the pathological condition is resolved without treatment.
In severe syndrome, toxic shock is observed, leading to impaired microcirculation and aggravating damage to parenchymal organs. Respiratory failure occurs with shortness of breath and deterioration of blood oxygenation, DIC with thromboembolism and profuse bleeding, heart rhythm is disturbed, and the kidneys fail as a result of acute tubular necrosis. Patients with streptococcal TSS in more than 50% of cases develop bacteremia and necrotizing fasciitis. In the long term, temporary loss of nails and hair, neurological disorders (paresthesia, memory disorders, fatigue) are possible.
Given the multi-organ nature of the disease, for diagnosis, it is necessary to evaluate both local changes on the part of the female organs and signs of impairment of other systems. In a comprehensive survey included:
- Examination by a gynecologist. Puffiness and hyperemia of the genital organs are detected, in some cases – poor purulent discharge from the cervical canal. Palpation can be determined by the pain in the appendages.
- Physical examination. In 100% of cases, there is a temperature increase of more than 38.9 ° C and a systolic pressure drop below 90 mm.
TSH syndrome is differentiated from sepsis and infectious diseases (measles, scarlet fever, leptospirosis, hepatitis B, Rocky Mountain spotted fever, typhoid fever, meningococcemia, viral exanthema). The patient is advised by an anesthesiologist-resuscitator, infectious disease specialist, cardiologist, surgeon, urologist, dermatologist, pulmonologist, and neuropathologist.
Treatment of toxic shock syndrome
When choosing a treatment regimen for toxic shock syndrome, it is important to consider influencing the factors that caused the disease and measures to stabilize the functions of the affected systems. The patient shows:
- Sanitation of the bacterial focus. First, remove the tampon, diaphragm, cap (if any) and wash the vagina with a sterile solution. If bacterial contaminated wounds are detected, excision of tissues with areas of necrosis is possible.
- Antibiotic therapy. The choice of drug is based on the results of determining sensitivity to antimicrobial agents. Prior to obtaining 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 the intravascular fluid volume and the stabilization of hemodynamic parameters. Depending on the nature of the disorder, the patient is poured in crystalloid solutions, electrolytes, fresh frozen blood plasma, platelet mass, etc.
- Vasopressor agents. If the correction of the volume of intravascular fluid does not allow for normalization of blood pressure, drugs with a pressor effect are administered.
In case of severe organ failure, the patient may be given hemodialysis (in case of acute renal failure), artificial ventilation of the lungs with positive pressure during expiration (in respiratory distress syndrome). A number of authors note a faster recovery in the appointment of corticosteroids and immunoglobulins.
Prognosis and prevention
In most cases, thanks to the achievements of modern gynecology, timely diagnosis and treatment of patients with staphylococcal TSS recover within 1-2 weeks, while the mortality rate at the present stage is 2.6%. Temperature and blood pressure are normalized within 2 days from the moment of hospitalization, and laboratory values - on the 7-14th day. The level of erythrocytes is restored in 4-6 weeks. When 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.