Toxic shock syndrome

Toxic shock syndrome (TSS) represents a heterogeneous group of disorders that results in hypotension, multiorgan system involvement, and a characteristic rash or soft tissue infection caused by staphylococcal or streptococcal exotoxins and enterotoxins. Staphylococcal TSS emerged in the late 1970s as an illness associated with highly absorbent tampons; subsequently it has been described with postoperative infections, burns, and various viral illnesses. Although the morbidity rate associated with staphylococcal TSS may be high, the mortality rate approximates 5%. Streptococcal TSS has emerged in the 1980s and into the 1990s as a disorder that results in rapid progression of soft tissue infection in the form of cellulitis, myositis, or necrotizing fasciitis due to pyogenic streptococcal group A exotoxin. The rapidity of progression of local infection to hypotension and multiorgan failure results in a mortality rate of 30-70%. In both forms of TSS, staphylococcal and streptococcal exotoxins function as superantigens, a unique mechanism of immune activation that results in an exuberant T-cell response and profound cytokine expression. The role of antibiotics is reviewed. The use of clindamycin in streptococcal TSS and the potential therapeutic role of intravenous immunoglobulin in both forms of this disorder are discussed as well.