Toxic shock syndrome

Toxic Shock Syndrome

Toxic shock syndrome is an acute, noncontagious systemic illness characterized by high fever, hypotension rash multi organ dysfunction and cutaneous desquamation during the early convalescent periods. 

Toxic shock syndrome is a toxin mediated acute life threatening illness, usually precipitated by infection with earlier staphylococcus aureus Or group A streptococcus also called streptococcus pyogens. 

Although this diseases has been frequently linked to use of tampons in menstruating women it can affect people of any gender and any age. 

This can occur with skin infections, burns and after surgery. 

Causes :- 

The pathogenesis of TSS proceeds as follows 

1. Human colonisation or infection by strain of S.aureus capable of producing a TSS toxin 

2.Toxic production

3.Toxic absorption

4.Intoxication

The anterior nasopharynx is principal site of carriage, others include the axillae, vagina and perineum. Among normal postmenarcheal European women the rate of vaginal colonisation is 5- 20% and is greatest during the menses. 

Pathophysiology :- 

Clinical manifestations :- 

1.High fever 

2.Nausea 

3.Vomiting

4.Abdominal pain

5.Severe muscle pain 

6. Profuse watery diarrhea

7. Skin rashes 

8. Low blood pressure

9.Peeling of skin of palms and soles of feet

10. Redness of eyes, mouth, throat and vagina

Management :- 

Treatment involves several key components :-

1) Identification and decontamination of the site of toxin production Drain or debride the lesion, remove foreign material, and irrigate copiously. Recent surgical wounds should be explored and irrigated even when signs of inflammation are absent. 

2) Aggressive fluid resuscitation: Loss of fluid into the extravascular compartment can be very substantial. Maintenance of cardiac filling pressures is critical in order to prevent end organ damage. Adult patients with TSS have required up to 10 L of fluid in the first 24 hr.

3) Administration of antistaphylococcal antibiotics:Semisynthetic penicillins have been widely used for TSS. Growing evidence, however, suggests that the protein synthesis inhibitor clindamycin is more efficacious in this illness. Accordingly, the author recommends treating suspected TSS patients with clindamycin (900 mg i.v. every 8 hours for adults, 13 mg/kg i.v. every 8 hours for children), either alone or in combination with a cell wall active agent (semisynthetic penicillin or vancomycin).If the diagnosis of TSS is initially uncertain, broader empiric coverage is appropriate.

4) General supportive care: Intensive care monitoring is often indicated. Replete calcium and magnesium, provide ventilatory, pressor, and inotropic support, manage rhabdomyolysis, renal dysfunction, and/or coagulopathy.

5) Administration of pooled human immunoglobin: This should be reserved for refractory cases or cases associated with an undrainable focus of infection. All commercial immunoglobulin preparations contain high levels of anti TSST-1 antibody. A single infusion of 400 mg/kg i.v. will generate a protective titre in a nonimmune patient. Those may include intravenous (IV) fluids, medications to raise blood pressure, equipment to aid breathing, dialysis and other measures to counteract the effects of the toxins. 

Prevention of Toxic shock syndrome :- 

1.women who had Toxic shock syndrome should avoid using tampons during menstruation as reinfection may occur the use of diaphragm and vaginal sponges may also increase the risk of Toxic Shock Syndrome. 

2. Prompt and through wound care will help to avoid Toxic shock syndrome. 

3. Women should use sanitary napkins instead of tampons.

 

4. All wounds should be kept clean and bandaged and monitor for sign of infection. 

5.Change the tampon every 4 to 6 hourly. 

6. Use of lowest absorbency tampons. 

7.Hand washing Before and after inserting tampons. 

8.Don't leave diaphragm or sponge for a long period of time. 

Reference

B. Venkatesan. Textbook of medical surgical nursing first edition. Published by Emess medical Publishers.