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Infectious Disease Online

Pathology of Toxic Shock Syndrome      

Dr Sampurna Roy MD           




The toxic shock syndrome is a sporadic, febrile illness that is characterized by fever, hypotension, and a desquamating rash.

Some of the symptoms resemble those of scarlet fever, a disease caused by the erythrogenic toxin of Streptococcus pyogenes.  

Staphylococcal Infection

The toxic shock syndrome may progress to renal and pulmonary failure and death.

The disease usually occurs in young, menstruating women, in whom it is usually associated with some brands of tampons.

The risk appears to be higher if tampons with high absorbency remain in place longer than usual.

However, the syndrome may also occur in nonmenstruating women, men, and children, in association with staphylococcal empyema, septic abortions, fasciitis, osteomyelitis, and abscesses.

In its acute phase the diagnosis of TSS is often uncertain.

The initial symptoms are nonspecific and numerous conditions need to be considered in the differential diagnosis.

The diagnosis can be confirmed, if at all, only in the convalescent phase by the skin desquamation or a rise in anti-TSST-1 antibody titre.

A search for a focus of infection is essential for differentiation from a non-menstrual TSS, even if there is an association with menstruation.

The toxic shock syndrome is thought to be  caused by only some strains of S. aureus, namely those that grow well in the environment provided by the tampon (in vagina and cervix).

Some studies suggest that the DNA of a lysogenic bacteriophage in those strains may enable S. aureus to produce a specific toxin.

Microscopic features:

Histologic studies of the liver from patients with the toxic shock syndrome have shown acute cholangitis with little or no cholestasis.

Acute cholangitis could account for the jaundice and hyperbilirubinemia reported in many patients with this condition.

Circulating toxin is thought to damage the bile ducts, rather than bacterial infection per se.


Further reading:

Toxic shock syndrome-like exanthematous disease in a 2-month-old infant.

Staphylococcal toxic shock syndrome: mechanisms and management.

[Streptococcal toxic shock syndrome].

Gram-positive bacterial superantigen outside-in signaling causes toxic shock syndrome.

Simultaneous isolation of emm89-type Streptococcus pyogenes strains with a wild-type or mutated covS gene from a single streptococcal toxic shock syndrome patient.

Prevalence of enterotoxin and toxic shock syndrome toxin genes in Staphylococcus aureus isolated from milk of cows with mastitis.

Maternal-fetal staphylococcal toxic shock syndrome with chorioamniotitis.

Prevalence of toxic shock syndrome toxin 1-producing Staphylococcus aureus and the presence of antibodies to this superantigen in menstruating women.




Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)  ;  Dermpath-India  ;   Soft Tissue Tumour Online ; Cardiac Path Online ;

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