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Atchade E, De Tymowski C, Grall N, Tanaka S, Montravers P. Toxic Shock Syndrome: A Literature Review. Antibiotics (Basel) 2024; 13:96. [PMID: 38247655 PMCID: PMC10812596 DOI: 10.3390/antibiotics13010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
Toxic shock syndrome (TSS) is a rare, life-threatening, toxin-mediated infectious process linked, in the vast majority of cases, to toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes. The pathophysiology, epidemiology, clinical presentation, microbiological features, management and outcome of TSS are described in this review. Bacterial superantigenic exotoxins induces unconventional polyclonal lymphocyte activation, which leads to rapid shock, multiple organ failure syndrome, and death. The main described superantigenic exotoxins are toxic shock syndrome toxin-1 (TSST-1) and enterotoxins for Staphylococcus aureus and Streptococcal pyrogenic exotoxins (SpE) A, B, and C and streptococcal superantigen A (SsA) for Streptococcus pyogenes. Staphylococcal TSS can be menstrual or nonmenstrual. Streptococcal TSS is linked to a severe group A streptococcal infection and, most frequently, to a necrotizing soft tissue infection. Management of TSS is a medical emergency and relies on early detection, immediate resuscitation, source control and eradication of toxin production, bactericidal antibiotic treatment, and protein synthesis inhibiting antibiotic administration. The interest of polyclonal intravenous immunoglobulin G administration as an adjunctive treatment for TSS requires further evaluation. Scientific literature on TSS mainly consists of observational studies, clinical cases, and in vitro data; although more data on TSS are required, additional studies will be difficult to conduct due to the low incidence of the disease.
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Affiliation(s)
- Enora Atchade
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
| | - Christian De Tymowski
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
- UFR Diderot, Paris Cité University, 75018 Paris, France;
- INSERM UMR 1149, Immunoreceptor and Renal Immunopathology, Bichat-Claude Bernard Hospital, 75018 Paris, France
| | - Nathalie Grall
- UFR Diderot, Paris Cité University, 75018 Paris, France;
- Bacteriology Department, Bichat Claude Bernard Hospital, AP-HP, Paris Cité University, 75018 Paris, France
- INSERM UMR 1137 Infection, Antimicrobials, Modelling, Evolution, 75018 Paris, France
| | - Sébastien Tanaka
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
- INSERM, UMR 1188, Diabetes Atherothrombosis Réunion Océan Indien (DéTROI), la Réunion University, 97400 Saint-Denis de la Réunion, France
| | - Philippe Montravers
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
- UFR Diderot, Paris Cité University, 75018 Paris, France;
- INSERM UMR 1152 ANR 10—LABX-17, Pathophysiology and Epidemiology of Respiratory Diseases, 75018 Paris, France
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Suzuki T, Matsuo T, Kijima Y, Hasegawa R, Ishikawa K, Yamanaka M, Kawai F, Komiyama N, Mori N. Acute heart failure associated with toxic shock syndrome due to methicillin-susceptible Staphylococcus aureus during the postpartum period: case report and systematic literature review. BMC Cardiovasc Disord 2022; 22:452. [PMID: 36309644 PMCID: PMC9617239 DOI: 10.1186/s12872-022-02903-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Toxic shock syndrome (TSS) caused by Staphylococcus aureus in the postpartum period is a rare but life-threatening disease. We present a case of acute heart failure as the initial presentation of TSS due to methicillin-susceptible Staphylococcus aureus (MSSA) and describe its clinical characteristics with a systematic literature review. CASE PRESENTATION A 34-year-old woman, 8 days after a normal vaginal delivery presented to our hospital with dyspnea and fever. She had jugular venous distension, bilateral leg edema, and erythema. Laboratory examinations revealed elevated NT-pro-BNP level of 3,233 pg/mL. Transthoracic echocardiography showed elevated tricuspid regurgitation peak gradient, with decreased respiratory variability of the inferior vena cava diameter and bilateral pleural effusions. The patient was hospitalized with suspicion of congestive heart failure. MSSA positive for toxic shock syndrome exotoxin-1 was detected in the culture of the perineal incision wound, and we diagnosed TSS caused by MSSA. Intravenous diuretics were administered, along with eventual cefazolin plus clindamycin. After 2 weeks of antimicrobial therapy, the patient showed improvement and was discharged. No recurrence was observed at the 24-month follow-up. CONCLUSION This is a rare case report of acute heart failure being the initial manifestation of TSS due to MSSA in the postpartum period. Clinicians should consider TSS as a possibility in postpartum patients with acute heart failure. This systematic review provides insights into its clinical features, treatment regimens, and prognosis of TSS by S. aureus in the postpartum period. TSS requires an appropriate, prompt diagnosis, because delayed treatment can be fatal.
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Affiliation(s)
- Takahiro Suzuki
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan.
| | - Takahiro Matsuo
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
| | - Yasufumi Kijima
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Ryo Hasegawa
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuhiro Ishikawa
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
| | - Michiko Yamanaka
- Department of Integrated Women's Health, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Fujimi Kawai
- St. Luke's International University Library, Tokyo, Japan
| | - Nobuyuki Komiyama
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Nobuyoshi Mori
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo, Japan
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Shibata T, Nakago S, Kato H, Tokuda H, Hosono S, Kotsuji F. Difficult maintenance of serum drug concentration in methicillin-resistant Staphylococcus aureus toxic shock syndrome during early puerperium. J Obstet Gynaecol Res 2022; 48:1484-1488. [PMID: 35315176 DOI: 10.1111/jog.15221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/18/2022] [Accepted: 02/26/2022] [Indexed: 11/29/2022]
Abstract
Toxic shock syndrome can be caused by methicillin-resistant Staphylococcus aureus (MRSA). During puerperium this condition is rare, and proper treatment during this period has not been clarified. Two patients developed toxic shock syndrome caused by MRSA soon after cesarean section. Despite the administration of antibiotics, both developed severe conditions and one of them required hysterectomy. The dosage was adjusted in the same way as nonpregnancy, but the actual drug concentration was significantly different from expectation. When there is severe infection during the early postpartum period, maintaining drug concentration at optimal levels may be difficult, and this could be life-threatening. Better understanding of the pharmacokinetics and establishment of a method to determine the optimal drug dose during puerperium is required.
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Affiliation(s)
- Takashi Shibata
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Satoshi Nakago
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Hiroki Kato
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Hisato Tokuda
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Sayoko Hosono
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Fumikazu Kotsuji
- Department of Obstetrics and Gynecology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
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Postpartum Methicillin-Resistant Staphylococcus aureus Toxic Shock Syndrome Caused by a Perineal Infection. Case Rep Obstet Gynecol 2018; 2018:2670179. [PMID: 30363971 PMCID: PMC6186360 DOI: 10.1155/2018/2670179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 08/30/2018] [Indexed: 11/18/2022] Open
Abstract
Although toxic shock syndrome (TSS) is rare, multiorgan failure can occur without early identification and appropriate therapy. In particular, a few cases of postpartum TSS due to methicillin-resistant Staphylococcus aureus (MRSA) have been reported. Here, we describe a rare case in which a 32-year-old Japanese woman had TSS due to MRSA that was caused by a perineal infection after a normal vaginal delivery. Twelve days after giving birth to a healthy child, she was readmitted to our hospital due to a 2-day fever and perineal pain without uterine tenderness. She developed emesis and watery diarrhea on the night of admission. On the second day, a diffuse cutaneous macular rash appeared over her trunk. Laboratory data revealed deteriorated renal function and thrombocytopenia. Her history and clinical results were compatible with a typical course of TSS. Administration of ceftriaxone and clindamycin was started immediately after admission and was effective. The patient recuperated steadily over the next week with desquamation of the skin. MRSA was isolated from her vaginal discharge and was found to produce TSS toxin 1 (TSST-1). Furthermore, since MRSA was not detected in the nasal and vaginal cavity during pregnancy, it suggests that vaginal colonization can also occur postpartum and be the disease source in mothers. Therefore, MRSA infections should be considered when treating for postpartum TSS.
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Gottlieb M, Long B, Koyfman A. The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. J Emerg Med 2018; 54:807-814. [PMID: 29366615 DOI: 10.1016/j.jemermed.2017.12.048] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/17/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately. OBJECTIVE This review provides an emergency medicine evidence-based summary of the current evaluation and treatment of TSS. DISCUSSION The most common etiologic agents are Staphylococcus aureus and Streptococcus pyogenes. Sources of TSS include postsurgical wounds, postpartum, postabortion, burns, soft tissue injuries, pharyngitis, and focal infections. Symptoms are due to toxin production and infection focus. Early symptoms include fever, chills, malaise, rash, vomiting, diarrhea, and hypotension. Diffuse erythema and desquamation may occur later in the disease course. Laboratory assessment may demonstrate anemia, thrombocytopenia, elevated liver enzymes, and abnormal coagulation studies. Diagnostic criteria are available to facilitate the diagnosis, but they should not be relied on for definitive diagnosis. Rather, specific situations should trigger consideration of this disease process. Treatment involves intravenous fluids, source control, and antibiotics. Antibiotics should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid. CONCLUSION TSS is a potentially deadly disease requiring prompt recognition and treatment. Focused history, physical examination, and laboratory testing are important for the diagnosis and management of this disease. Understanding the evaluation and treatment of TSS can assist providers with effectively managing these patients.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Andrews JI, Fleener DK, Messer SA, Kroeger JS, Diekema DJ. Screening for Staphylococcus aureus carriage in pregnancy: usefulness of novel sampling and culture strategies. Am J Obstet Gynecol 2009; 201:396.e1-5. [PMID: 19716114 DOI: 10.1016/j.ajog.2009.06.062] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 05/14/2009] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the most sensitive strategy for the detection of Staphylococcus aureus among pregnant women and newborn infants. STUDY DESIGN We obtained cultures for S aureus from 5 body sites of women at 35-37 weeks' gestation. We obtained cultures from their newborn infants before hospital discharge. RESULTS Of 209 women who were screened, 29% of the women had at least 1 culture that was positive for S aureus; 5% of infants were S aureus carriers. The sensitivities of each site for S aureus detection were 52% nares, 50% throat, 13% rectum, 8% vagina, and 10% skin. The most sensitive combination of 2 sites was nares and throat (88%). Perinatal transmission of S aureus occurred in 4 women. Maternal methicillin-resistant S aureus carriage rate was 1%. Two infants carried the USA300 methicillin-resistant S aureus. CONCLUSION Screening single body sites is insensitive for the detection of S aureus carriage in pregnancy. Sampling nares and throat is essential to the identification of S aureus carriers.
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