Toxic Shock Syndrome (TSS): A Rapid Guide for Resident Doctors

What Is Toxic Shock Syndrome?

Toxic Shock Syndrome (TSS) is a rare but life-threatening multisystem disease caused by bacterial exotoxins, primarily Staphylococcus aureus (menstruation-related) or Streptococcus pyogenes (non-menstrual). It presents like sepsis but with shock, rash, and multi-organ dysfunction.

Key Points for History-Taking

When a patient presents acutely unwell with fever and hypotension, always think of TSS as a differential. Here’s your focused question queue for the history:

Red Flag Questions to Ask:

Time of onset & progression

• “When did your symptoms start?”

• “Has it worsened rapidly over hours?”

Fever & systemic symptoms

• “Have you had any high fevers, chills, or sweats?”

• “Are you feeling dizzy or faint?”

 Rash

• “Have you noticed a sunburn-like rash?”

Menstrual history (if applicable)

• “Are you on your period?”

• “Are you using tampons or menstrual cups?”

Recent procedures or wounds

• “Any recent surgery, childbirth, or trauma?”

• “Any wounds or skin infections?”

GI or urinary symptoms

• “Any vomiting or diarrhoea?”

• “Any difficulty passing urine?”

Medication/Allergy/Immunosuppression

• “Are you on any immunosuppressive meds?”

Examination Findings to Look For

TSS may initially appear like sepsis or anaphylaxis. Use a structured approach: ABCDE, then detailed systemic examination.

General Observations

• Toxic, flushed appearance

• Febrile (>38.9°C)

• Hypotension (SBP <90 mmHg or MAP <65)

Skin

• Diffuse erythematous rash, “sunburn-like”

• Desquamation, especially palms and soles (appears later)

• Petechiae or purpura (suggests strep TSS)

• Localized skin infection, cellulitis, surgical site redness

CNS

• Confusion or altered mental status

CV/Resp

• Tachycardia

• Tachypnea or respiratory distress (ARDS may develop)

GI/Other

• Abdominal tenderness

• Conjunctival or mucosal hyperemia

Investigations to Send

Basic Bloods

• FBC: Leukocytosis or leukopenia, thrombocytopenia

• CRP/ESR: Elevated

• U&Es, LFTs: Evidence of multiorgan dysfunction

• Clotting profile & D-dimer: DIC screen

• Lactate: Elevated if shocky

Cultures

• Blood cultures ×2

• Urine MC&S

• Wound swabs / throat swab / vaginal swab if relevant

Imaging

• CXR: If respiratory signs or ARDS suspected

• Pelvic US: If retained tampon or post-partum cause suspected

Management Plan

TSS is a medical emergency. Early recognition and aggressive resuscitation + antibiotics + source control are crucial.

Immediate Resuscitation (ABCDE)

• High-flow O2

• IV access ×2, fluid resuscitation with crystalloids (e.g. 20–30 mL/kg bolus)

• Monitor vitals continuously

• Consider ICU if deteriorating or requiring vasopressors

  
  

Empirical Antibiotics (Do Not Delay)

According to RCEM, BMJ Best Practice, NICE:

• IV Clindamycin 600–900 mg q8h

  (inhibits toxin production)

• PLUS

• IV Flucloxacillin 2 g q6h

  
  

  (if S. aureus suspected)

• OR

• IV Ceftriaxone or Piperacillin-Tazobactam

  
  

  (if unclear source or polymicrobial)

If Streptococcal TSS suspected: Add IV Benzylpenicillin

Source Control

• Remove tampon or menstrual cup immediately

• Drain abscesses

• Debride infected wounds

• Review for surgical intervention if necrotizing fasciitis suspected

Additional Support

• Vasopressors (if fluids insufficient): Noradrenaline is first-line

• IVIG: Consider in streptococcal TSS, as per NICE

• Corticosteroids: Role unclear but may be considered in severe shock

• ITU Referral: Early if multi-organ support is needed

Clinical Pearls for Junior Doctors

• A rash with shock should scream TSS in your head.

• Always ask about tampon use, wounds, or recent surgery.

• Clindamycin saves lives—not just for bacteria, but for toxin inhibition.

• Treat first, culture later.

• Never hesitate to escalate to seniors or ICU early.

Follow-Up and Disposition

• Admit under medical or surgical depending on source

• Expect ICU support in moderate to severe cases

• Educate patient on recurrence risk, especially with tampon use

Summary Table: TSS at a Glance

Feature	Notes
Common pathogens	S. aureus, Strep pyogenes
Key signs	Fever, rash, hypotension, confusion
Investigations	Cultures, labs for end-organ damage
Initial treatment	IV fluids + antibiotics + remove source
Specific antibiotics	Clindamycin + β-lactam
ICU referral	If shock/multi-organ failure