Staphylococcal Toxic Shock Syndrome
        (Tampon Syndrome)
        Department of Obstetrics and Gynaecology
        Staphylococcal aureus producing exotoxins causes diseases because they are superanatigens activating T-cells resulting in massive cytotoxin production interleukins tumor necrosis factor and interferon).
        Toxic shock syndrome toxin (Superantigens) -1 (TSST-1) and other enterotoxins (A, C, D, E and H)
        Methecilin resistents staphylococcal aureus can cause the syndrome.

        Symptoms:
        Temperature > 38,9oC, hypotension < 90 mmHg
        Multisystem involment: 3 or more of the following.
        Gastric intestinal: vomiting and diarrhea.
        Muscular: Severe myoalgia CPK > 2 times normal upper limit.
        Mucous membranes hyperemia.
        Renal: Se-creatinin > 2 times upper limit or pyuria Hepatic: Bilirubin transaminase > 2 times normal upper limit.
        Hemathologic: Platlets < 100.000 µ/L
        CNS system: Deterioration.
        All patients have fever, hypotension and skin manifestation (macular erythema) with a mean of 2 days after surgery with desquamation 1-2 weeks after onset of illness, particularly involment palms and soles.

        Differential diagnose:
        Streptococcal TTS (severe pain), meningococcemia (petechia) and Rocky Mountain spotting fever.

        Treatment:
        • Extensive fluid replacement for many days (10-20 liters/day)
        • Remove tampons
        • Drainage of any identified focus
        • Clindamycin (600 - 900 mg i.v) q 8 hours plus Vancomycin 30 mg/kg/day in two divided doses, Nafcillin 2 g IV q 4h/
        • Intravenous Immunoglobulin (IVIG) 400 mg/kg over several hours
        • Corticosteroid. Methyl prednisoline 10-30 mg/days
        • Immune modulatory agents? re: Pentoxylline

        Reference:
        1) Darenberg J, Ihendyane N, Sjölin J, Aufwerber E et al. Intravenous Immunoglobulin G Theraphy in Streptococcal Toxic Shock Syndrome: A European randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2003;37:333-40.

        2) Kotb M, Norrby-Teglund A, McGeer A, El-Sherbini H et al. An immunogenetic and molecular basis for differences in outcome of invasive group A streptococcal infections. Nature Medicine 2002;8(12):1398-1404.

        3) Udagawa H, Oshio Y, Shimuzu Y. Serious group A streptococcal infection around delivery. Obstet Gynecol 1999;94:153-7.

        4) www.Infpreg.com

        5) www.uptodate.com 2007

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