TSS can be divided into menstrual and nonmenstrual. The majority of menstrual cases of
TSS are associated with tampon use (108). Nonmenstrual cases are caused by abscesses,
cellulitis, bursitis, postpartum infections, vaginal infections, sinusitis, burn wounds, insect
bites, and surgical procedures (104,109).
The diagnosis of TSS is based on the CDC diagnostic criteria (4). AlthoughS. aureusis
isolated from mucosal or wound sites in 80% to 90% of patients with TSS, this criterion is not
required for diagnosis.S. aureusis only recovered from blood cultures 5% of the time (108).
Other laboratory abnormalities may include hypocalcemia, elevated liver enzymes, elevated
creatinine, thrombocytopenia, pyuria, and proteinuria (106).
Streptococcal TSS
The clinical picture of TSS caused by group A and B streptococci is similar to that caused by
S. aureus. Skin and soft-tissue infections are often the source of invasive group A and
B streptococci (92,94). Minor trauma, injuries resulting in hematoma or bruising, surgery,
viral infections, and use of nonsteroidal anti-inflammatory drugs are associated with
the development of severe streptococcal infections (94). One particular difference from
staphylococcus-associated TSS is that streptococci can frequently (60% of the time) be isolated
from blood culture (110). The mortality rates for streptococcal TSS are five times higher than
those for the staphylococcal TSS (111).
Staphylococcal Scalded Skin Syndrome
Staphylococcal scalded skin syndrome (SSSS) describes a spectrum of superficial blistering
skin disorders caused byS. aureusstrains that produce exfoliative toxins (112). The clinical
spectrum of SSSS includes a localized form, bullous impetigo, and a generalized form,
pemphigus neonatorum.
The exfoliative toxins are also known as epidermolytic toxins, epidermolysins, and
exfoliatins. Production of exfoliative toxin occurs in 5% of allS. aureusstrains (113,114). The
two main exfoliative toxins are exfoliative toxin A (ETA) and exfoliative toxin B (ETB)
(115–117). More recently, two new toxins, exfoliative toxin C (ETC) and exfoliative toxin D (ETD),
have been identified (117).
Bullous impetigo (also known as bullous varicella or measles pemphigoid) presents with
a few localized, fragile, superficial blisters that are filled with colorless, purulent fluid (118).
The lesions re-epithelialize in five to seven days. This form of SSSS is usually seen only in
children. Typically, there are no associated systemic symptoms. The lesions are located in the
area of the umbilicus and perineum in infants and over the extremities in older children (119).
Figure 7 Desquamation of left palm of a patient with TSS.Abbreviation: TCC, toxic shock syndrome.Source:
Courtesy of the CDC, Public Health Image Library.
34 Engel et al.