Rosen & Barkin's 5-Minute Emergency Medicine Consult (722 page)

• Aggressive fluid replacement
  
  • The 1st 24 hr may require 4–20 L of crystalloid and/or fresh frozen plasma (colloid)
    
  • Caution:
    Large amounts of IV fluids and pressors used to treat refractory hypotension can result in rapid onset pulmonary edema
    
  • Pressors (dopamine/norepinephrine) if fluid correction fails to restore normal arterial pressure
    

• Search for and treat the focus of infection
  
• Remove the source of infection (e.g., tampon, nasal or wound packing)
  
• Early surgical/gynecologic consultation if drainage or débridement of infectious sites necessary
  
• Antibiotics
  
  • Recommended to reduce recurrence, but have not been shown to alter the course of the initial infection
    
  • Clindamycin and linezolid are potent suppressers of bacterial toxin synthesis
    
  • Clindamycin or linezolid
    +
    vancomycin for TSS
    
  • Linezolid
    +
    vancomycin for TSS with extensive infection
    
  • If TSS due to known methicillin-susceptible
    S. aureus
    then clindamycin
    +
    oxacillin or nafcillin
    
  • Clindamycin
    +
    imipenem or meropenem or ticarcillin–clavulanate or piperacillin–tazobactam for STSS
    
• IV immunoglobulin (IVIG) treatment:
  
  • May be efficacious in streptococcal toxic shock, but no controlled trials have proven efficacy in staphylococcal TSS.
    
  • May initiate if no response to fluids, pressors, and antibiotics in patients with pulmonary edema and hypotension
    

• Clindamycin: 600–900 mg (peds: 20–40 mg/kg/24 h) IV q6–8h
  
• Dopamine: 2–20 μg/kg/min IV, titrate to BP
  
• Linezolid: 600 mg (peds: 10 mg/kg/12 h) IV q12h
  
• Meropenem: 1 g IV q8h
  
• Nafcillin: 1.5 g (peds: 100 mg/kg/24 h) IV q4h
  
• Norepinephrine: 0.01–3 mcg/kg/min IV, titrate to BP
  
• Oxacillin: 1–2 g (peds: 50–100 mg/kg/24 h) IV q4h
  
• Piperacillin–tazobactam: 4.5 g q6h
  
• Ticarcillin–clavulanate: 3.1 g q4h
  
• Vancomycin: 30 mg/kg QD IV div. in 2 doses (peds: 40 mg/kg QD IV div. in 4 doses)
  
• Staphylococcal TSS: IVIG, 400 mg/kg over several hours
  
• Streptococcal TSS: IVIG 1 g/kg on day 1 then 0.5 g/kg on days 2 and 3
  

FOLLOW-UP

• Cases necessitateadmission
  
• ICU admission for critically ill or those in shock
  

None

Early surgical/gynecologic consultation if drainage or débridement is needed

• Patients who are bacteremic are treated for a minimum of 14 days:
  
  • Depending on the clinical course
    
  • Continue treatment for 14 days from the last positive culture.
    
• Screening for
  S. aureus
  nasal carriage in patient with
  S. aureus
  TSS and eradication of the carrier state with mupirocin
  

• Consider the diagnoses of staphylococcal TSS and GAS TSS
  
• Ensure adequate supportive care for hypotension in TSS
  
• Prompt and aggressive exploration and débridement of suspected deep-seated infection
  
• Empiric broad-spectrum antibiotics including clindamycin or linezolid is recommended
  

• DeVries AS, Lesher L, Schlievert PM, et al. Staphylococcal toxic shock syndrome 2000–2006: Epidemiology, clinical features, and molecular characteristics.
  PLoS One.
  2011;6(8):e22997.
  
• Darenberg J, Ihendyane N, Sjölin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: A European randomized, double-blind, placebo-controlled trial.
  Clin Infect Dis
  . 2003;37:333–340.
  
• Lappin E, Ferguson AJ: Gram-positive toxic shock syndromes.
  Lancet Infect Dis
  . 2009;281–290.
  
• O’Brien KL, Beall B, Barrett NL, et al. Epidemiology of invasive group A streptococcus disease in the United States, 1995–1999.
  Clin Infect Dis.
  2002;35:268–276.
  
• Stevens DL, Wallace RJ, Hamilton SM, et al. Successful treatment of staphylococcal toxic shock syndrome with linezolid: A case report and in vitro evaluation of the production of toxic shock syndrome toxin type 1 in the presence of antibiotics.
  Clin Infect Dis.
  2006;42:729–730.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Streptococcal Infections
  
• Kawasaki Disease
  
• Meningococcemia
  
• Leptospirosis
  

CODES

040.82 Toxic shock syndrome

BASICS

• Toxoplasma gondii
  —intracellular protozoan parasite:
  
  • 3 forms:
    
    • Tachyzoite: Asexual invasive form
      
    • Tissue cyst: Persists in tissues of infected hosts during chronic phase
      
    • Oocyst: Contains sporozoites and produced during sexual cycle in cat intestine
      
• Transmission:
  
  • Ingesting tissue cysts or oocysts:
    
    • Ingesting undercooked meat
      
    • Vegetables contaminated with oocysts
      
    • Contact with cat feces, through cat or soil
      
  • Transplacental
    
  • Blood product
    
  • Organ transplantation
    

• 70% of adults seropositive
  
• Asymptomatic in most immunocompetent patients
  
• Worldwide; cats are the common host
  
• Incubation is 7 days with a range of 4–21 days
  

DIAGNOSIS

4 types of infection

Immunocompromised Host

• CNS:
  
  • Subacute presentation (90%)
    
  • Encephalitis
    
  • Headache
    
  • Altered mental status
    
  • Fever
    
  • Seizures
    
  • Cranial nerve palsies
    
  • Spinal cord lesions
    
  • Cerebellar signs
    
  • Meningitis-like symptoms
    
  • Movement disorders
    
  • Neuropsychological symptoms:
    
    • Psychosis
      
    • Paranoia
      
    • Dementia
      
    • Anxiety
      
    • Agitation
      
• Pulmonary:
  
  • Pneumonitis
    
  • Prolonged febrile illness
    
  • Nonproductive cough
    
  • Dyspnea
    

Immunocompetent Host

• 90% are asymptomatic
  
• Lymphadenopathy, usually cervical
  
• Fever
  
• Malaise
  
• Mononucleosis-like syndrome with macular rash and hepatosplenomegaly
  
• Headache
  
• Sore throat
  
• Night sweats
  
• Maculopapular rash
  
• Urticaria
  
• Usually, self-limited process; resolves in 2–12 mo
  
• Rarely presents with pneumonitis or encephalitis
  

Ocular Toxoplasmosis

• Blurred vision
  
• Scotoma
  
• Pain
  
• Photophobia
  
• Retina:
  
  • Small clusters of yellow-white cotton-like patches
    
  • Chorioretinitis; affects 85% of young adults with untreated congenital infection
    

Congenital Toxoplasmosis

• Results from an asymptomatic acute infection during pregnancy
  
• 1st trimester:
  
  • Spontaneous abortion
    
  • Stillbirth
    
  • Severe disease up to 25% of the time
    
• 2nd or 3rd trimester:
  
  • 50–60% chance of acquiring congenital toxoplasmosis
    
  • 2% fatal
    
• Most asymptomatic at birth
  
• Delayed onset. 70–90% asymptomatic at birth:
  
  • CNS disease
    
  • Ocular disease (blindness months to years later)
    
  • Lymphadenopathy
    
  • Hepatosplenomegaly
    
  • At birth, may have maculopapular rash, lymphadenopathy, hepatomegaly, splenomegaly, jaundice, thrombocytopenia