Toxic shock syndrome

Introduction to toxic shock syndrome Toxic shock syndrome (TSS) is a syndrome characterized by fever, rash, syncope, hypotension or shock and multiple systemic lesions, mostly caused by one or more toxins produced by Staphylococcus aureus. . basic knowledge The proportion of sickness: 0.003%-0.005% Susceptible people: no specific population Mode of infection: non-infectious Complications: erect hypotension fainting

Causes of toxic shock syndrome

(1) Causes of the disease

The exact cause of toxic shock syndrome is unknown, but almost all cases are associated with the phage 1 group of S. aureus exotoxin-producing strains, which produce toxic shock syndrome toxin-1 or related exotoxins. The bacteria are found in the mucous membranes (nasopharynx, vagina, trachea) or necrotic separation sites (accumulation, abscesses) and in the vagina of women undergoing it, and it is speculated that women who already have colonies in the vagina and use vaginal plugs are the most dangerous. In the case of toxic shock syndrome, it is likely that mechanical or chemical factors associated with vaginal plugs result in increased production of bacterial exotoxins, which can enter the bloodstream through the damaged mucosa or uterus.

The virulence factor is a toxic shock syndrome toxin I (TSST-I) produced by Staphylococcus aureus (bacteriophage I), previously thought to be caused by staphylococcal endotoxin F or purulent exotoxin C, occasionally group A - Hemolytic streptococcus can also cause this disease.

(two) pathogenesis

Almost all cases are infected with Staphylococcus aureus. Most pathogens can be isolated from women's vagina, cervical mucosa, menstrual tampon or other parts of the body. Early patients may have symptomatic vaginitis. Also seen in patients with nasal tamponade after nasal plastic surgery and patients with kidney, lung or soft tissue staphylococcal infection.

The susceptibility of patients is related to the lack of protective antibodies against toxins, and the activation of cytokines plays a role in the pathogenesis.

Toxic shock syndrome prevention

In addition to the eradication of Staphylococcus aureus, there are no other sure prevention methods (primary or secondary prevention), but caution is given to women not to use vaginal plugs throughout the menstrual period, but to use sanitary napkins intermittently or to take other hygiene Measures.

Patients suspected of toxic shock syndrome should be hospitalized immediately and intensively treated, immediately remove vaginal plugs, diaphragms or other foreign bodies, must be supplemented with liquids and electrolytes to prevent and treat hypovolemia, hypotension or shock, due to the wide range of fluids Loss into the whole body tissue, shock may be deep and stubborn, so sometimes it is necessary to supplement the liquid and electrolyte in large quantities. The specimen should be taken from the mucosal surface and blood for Gram staining and culture; after taking the material, start with -lactamase resistant penicillin or cephalosporin. Mycomycin treatment.

1. In the units prone to pyoderma (such as some factories, agricultural machinery stations, primary schools, etc.), extensive publicity and education on the prevention and treatment of suppurative skin diseases, regular preventive inspections, as far as possible to eliminate all factors.

2. Pay attention to skin hygiene, strengthen physical exercise and increase skin resistance.

3. Maintain the integrity of skin function. For skin diseases, especially pruritic skin diseases, timely treatment should be carried out to prevent skin damage and avoid irritation such as scratching and skin friction.

4. Clothes, towels, basins, etc. are prohibited from public use to prevent contact with infection. The patient should be properly isolated. The dressings and contact materials used by the patient should be strictly disinfected or burned. During the illness, it is forbidden to use the liquid to clean the skin lesions. Wash the affected area with tap water to prevent extension.

5. When you are sick, you should ban alcohol or spicy food, and eat less food.

Toxic shock syndrome complications Complications, orthostatic hypotension, fainting

The syndrome can progress to orthostatic hypotension, fainting, shock and death within 48 hours. Skin loss and skin exfoliation can occur between the 3rd and 7th day after onset, especially in the palms and soles. The skin, other organs are also often involved, can cause mild non-hemolytic anemia, moderate leukocytosis dominated by immature granulocytes and early thrombocytopenia and subsequent thrombocytosis, although clinically important bleeding Rarely occurs, but prothrombin time and partial clotting time have a tendency to prolong.

Toxic Shock Syndrome Symptoms Common symptoms Venous rash Hematuria faint plaque syncope Drowsiness Shock Nitrogenemia Hypotension Leukocytosis

Sudden onset, with persistent high fever (39~40.5 °C), headache, sore throat, non-suppurative conjunctivitis, deep sleepiness, intermittent confusion, no focal neurological signs, vomiting, massive watery diarrhea and diffuse day Sun-like erythroderma, the syndrome can progress to orthostatic hypotension, fainting, shock and death within 48 hours. Skin loss and skin exfoliation can occur between the 3rd and 7th day after onset. Especially found in the skin of the palms and soles.

Other organs are also often involved, causing mild non-hemolytic anemia, moderate leukocytosis dominated by immature granulocytes, and early thrombocytopenia and subsequent thrombocytosis, although clinically significant bleeding is rare. However, prothrombin time and partial clotting time have a prolonged tendency. In the first week of the disease, abnormal liver function (hepatitis) and rhabdomyolysis can be found in the test. Cardiopulmonary involvement can also occur, which is characterized by peripheral edema and pulmonary edema (central Abnormal venous pressure, suggesting adult respiratory distress syndrome, especially in children with severe hypotension and insufficient blood flow to the limbs, and almost all renal abnormalities, characterized by decreased urine output and increased blood urea nitrogen and creatinine .

Toxic shock syndrome is similar to Kawasaki syndrome, but can be identified according to clinical manifestations. Kawasaki syndrome usually occurs in children under 5 years of age, does not cause shock, azotemia or thrombocytopenia, rash is maculopapular rash, others should Considering the identification of scarlet fever, Reye syndrome, staphylococcal scalded skin syndrome, meningococcal bacteremia, Rocky Mountain spotted fever, leptospirosis and viral rash disease, these diseases can be based on specificity Clinical manifestations, culture and serological tests were excluded.

More common in previous physical health, young women on the 1st to 6th day of menstruation, especially menstrual application of sanitary tampon, but can also occur in menopausal women, men and children, a small number of patients with general malaise, low fever, myalgia or Prodromal symptoms such as vomiting, sudden onset, sudden high fever, body temperature can be higher than 38.9 ° C, often accompanied by chills, hypotension often occurs within 72 hours of fever, adult systolic blood pressure below 90mmHg, with erectile syncope or shock.

The rash can occur on the first day. The most common manifestation is extensive erythema, which resolves within 3 days. Scarlet fever-like rash and mound pustule can also occur. The hand and foot are obviously swollen. There may be extensive mucosal erythema, subconjunctival hemorrhage, oral cavity. Esophageal, vaginal and bladder mucosal ulcers, often accompanied by itching, sometimes blisters and bullae, maculopapular rash, purpura, desquamation are highly characteristic, occurring 10 to 21 days after onset, can be limited to the fingertips or involving The entire palmar skin or generalized, reversible plaque alopecia or rest stage hair loss, A transverse and partial nail loss is a late non-specific manifestation.

Multiple organ system damage occurred, gastrointestinal system damage vomiting, diarrhea; muscle system damage muscle pain, creatine phosphokinase increased; renal system damage with renal failure, elevated urine creatinine, elevated blood urea nitrogen; Hepatic damage has bilirubin, ALT, AST increased; blood system damage has platelets less than 100,000 / mm3; central nervous system damage has directional disorders or changes in consciousness.

Examination of toxic shock syndrome

Pathogen culture and serological tests are the key to the diagnosis of this disease.

Leukocytosis, left nucleus shift, thrombocytopenia in some patients, prolonged prothrombin time, liver function or renal dysfunction, blood, nose, pharynx and vaginal secretions can be isolated to coagulase-negative Staphylococcus aureus (phage I group).

Without characteristic histological manifestations, the dermis may have infiltration of mononuclear cells around the blood vessels and papillary edema. In cases of blister formation, fissures occur under the epidermis.

Diagnosis and diagnosis of toxic shock syndrome

Diagnostic criteria

1. Sudden high fever.

2. The rash is often a diffuse red spotted rash.

3. Skin desquamation occurs 1 to 2 weeks after onset.

4. Hypotension or orthostatic syncope.

5. At least 3 or more organs are damaged in the body.

6. Blood, throat swab, cerebrospinal fluid bacterial culture negative, can also be positive, all the above points are consistent, can be diagnosed, the lack of a certain is considered suspicious cases.

Identification with adult Kawasaki disease, staphylococcal scarlet fever, blood, vaginal and nasal secretions, urine, etc., to observe the presence or absence of Staphylococcus aureus, and exclude other pathogen infections.

Differential diagnosis

Toxic shock syndrome is similar to Kawasaki syndrome, but can be identified according to clinical manifestations. Kawasaki syndrome usually occurs in children under 5 years of age, does not cause shock, azotemia or thrombocytopenia, rash is maculopapular rash, others should Considering the identification of scarlet fever, Reye syndrome, staphylococcal scalded skin syndrome, meningococcal bacteremia, Rocky Mountain spotted fever, leptospirosis and viral rash disease, these diseases can be based on specificity Clinical manifestations, culture and serological tests were excluded.

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