Toxic shock syndrome

The diagnostic criteria for streptococcal and staphylococcal TSS were established for research purposes, and the sensitivity and specificity of these criteria have not been validated in the clinical setting. Optimising patient outcomes often requires treatment prior to the patient meeting the CDC case definition.

CDC case definition: streptococcal toxic-shock syndrome (STSS)

Clinical manifestations:[2]Centers for Disease Control and Prevention. Streptococcal toxic shock syndrome (STSS): 2010 case definition. 2010 [internet publication].​ https://ndc.services.cdc.gov/case-definitions/streptococcal-toxic-shock-syndrome-2010 ​​

• Hypotension: systolic BP ≤90 mmHg for adults or less than fifth percentile by age for children aged less than 16 years

• Multisystem involvement with 2 or more of the following:

  • renal impairment (creatinine ≥2 mg/dL for adults or greater than or equal to twice the upper limit of normal for age; in patients with pre-existing renal disease, a greater than 2-fold elevation over the baseline level)

  • coagulopathy (platelets ≤100,000/mm³, or disseminated intravascular coagulation defined by prolonged clotting times, low fibrinogen level, and the presence of fibrin degradation products)

  • hepatic impairment (alanine aminotransferase, aspartate aminotransferase, or total bilirubin levels greater than or equal to twice the upper limit of normal for the patient's age; in patients with pre-existing liver disease, a greater than 2-fold increase over the baseline level)

  • acute respiratory distress syndrome (defined by acute onset of diffuse pulmonary infiltrates and hypoxaemia in the absence of cardiac failure or by evidence of diffuse capillary leak manifested by acute onset of generalised oedema, or pleural or peritoneal effusions with hypoalbuminaemia)

  • a generalised erythematous macular rash that may desquamate

  • soft-tissue necrosis, including necrotising fasciitis or myositis, or gangrene.

Laboratory criteria:

• Isolation of group A Streptococcus.

Probable case: a case which meets the clinical case definition in the absence of another identified aetiology for the illness and with the isolation of group A Streptococcus from a non-sterile site.

Confirmed case: a case that meets the clinical case definition and with isolation of group A Streptococcus from a normally sterile site (e.g., blood or cerebrospinal fluid [CSF] or, less commonly, joint, pleural, or pericardial fluid).

CDC case definition: toxic-shock syndrome (TSS) other than streptococcal

Clinical manifestations:[3]Centers for Disease Control and Prevention. Toxic shock syndrome (other than streptococcal ) (TSS): 2011 case definition. Apr 2021 [internet publication]​. https://ndc.services.cdc.gov/case-definitions/toxic-shock-syndrome-2011 ​​

• Fever: temperature ≥38.9°C (102.0°F)

• Rash (diffuse macular erythroderma)

• Desquamation 1 to 2 weeks after onset of rash

• Hypotension: systolic BP ≤90 mmHg for adults or less than fifth percentile by age for children aged less than 16 years

• Desquamation 1 to 2 weeks after onset of illness, particularly involving palms and soles

• Multi-system involvement with 3 or more of the following organ systems:

  • gastrointestinal (vomiting or diarrhoea at onset of illness)

  • muscular (severe myalgia or creatine phosphokinase level at least twice the upper limit of normal)

  • mucous membrane (vaginal, oropharyngeal, or conjunctival hyperaemia)

  • renal (urea or creatinine at least twice the upper limit of normal for laboratory, or urinary sediment with pyuria in the absence of urinary tract infection)

  • hepatic (total bilirubin, alanine aminotransferase enzyme, or aspartate aminotransferase enzyme levels at least twice the upper limit of normal for laboratory)

  • haematological (platelets less than 100,000/mm³)

  • central nervous system (disorientation or alterations in consciousness without focal neurological signs when fever and hypotension are absent).

Laboratory criteria:

• Negative blood or CSF cultures (blood culture may be positive for Staphylococcus aureus)

• Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles.

Probable case: a case which meets the laboratory criteria and in which 4 or 5 of the clinical findings are present.

Confirmed case: a case which meets the laboratory criteria and in which all 5 of the clinical findings are present (including desquamation, unless the patient dies before desquamation).