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J Emerg Med. 2018 Jun;54(6):807-814. doi: 10.1016/j.jemermed.2017.12.048. Epub 2018 Jan 20.

The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature.

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Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois.
Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas.



Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately.


This review provides an emergency medicine evidence-based summary of the current evaluation and treatment of TSS.


The most common etiologic agents are Staphylococcus aureus and Streptococcus pyogenes. Sources of TSS include postsurgical wounds, postpartum, postabortion, burns, soft tissue injuries, pharyngitis, and focal infections. Symptoms are due to toxin production and infection focus. Early symptoms include fever, chills, malaise, rash, vomiting, diarrhea, and hypotension. Diffuse erythema and desquamation may occur later in the disease course. Laboratory assessment may demonstrate anemia, thrombocytopenia, elevated liver enzymes, and abnormal coagulation studies. Diagnostic criteria are available to facilitate the diagnosis, but they should not be relied on for definitive diagnosis. Rather, specific situations should trigger consideration of this disease process. Treatment involves intravenous fluids, source control, and antibiotics. Antibiotics should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid.


TSS is a potentially deadly disease requiring prompt recognition and treatment. Focused history, physical examination, and laboratory testing are important for the diagnosis and management of this disease. Understanding the evaluation and treatment of TSS can assist providers with effectively managing these patients.


Staphylococcus aureus; Streptococcus pyogenes; desquamation; erythroderma; fever; hypotension; infection; rash; toxic shock syndrome; toxin

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