Toxic shock syndrome

TSS · staphylococcal toxic shock syndrome · streptococcal toxic shock syndrome · STSS · toxic shock

Toxin-mediated shock with a diffuse red rash - recognise it at the front door, because the rash is subtle and the shock is not.

ADMITBand A

Red flags

Fever plus hypotension plus a diffuse erythema - treat as toxic shock now
Severe pain at a soft tissue focus - look for necrotising infection, which is a surgical emergency in its own right
Any retained foreign body: tampon, nasal pack, wound packing - remove it
Rapidly rising lactate or falling platelets

Recognise

On light skin

Diffuse blanching macular erythema like sunburn, including the palms and soles, in a shocked and febrile patient, with later desquamation.

On brown and black skin

A diffuse blanching erythema is one of the easiest signs to miss entirely in brown and black skin, and its absence is not evidence against the diagnosis. Examine the palms and soles, where involvement is characteristic and pigment interferes least, and check the conjunctivae and oral mucosa for the hyperaemia that often accompanies it. The later desquamation of the palms and soles is tone-independent and may be the first thing anyone notices - but it arrives far too late to be useful in the ED. Diagnose this on physiology, not on colour.

In any skin tone

Fever with hypotension and a diffuse rash - the triad that should trigger the thought
Rapid onset and rapid deterioration
Multi-organ involvement: vomiting and diarrhoea, myalgia, renal impairment, deranged liver function, thrombocytopenia, confusion
Mucosal hyperaemia - conjunctival injection, strawberry tongue
Look for a source: tampon, nasal packing, a surgical or burn wound, a skin or soft tissue infection, or recent varicella in a child
Streptococcal TSS is frequently accompanied by necrotising soft tissue infection and is more likely to be severely painful at a focus

Distribution

Diffuse blanching erythroderma, often described as resembling sunburn, involving the palms and soles. Desquamation of the palms and soles conventionally follows one to two weeks later (an interval widely taught rather than one taken from the sources cited here), by which time the patient is usually no longer in the ED.

Photographs

Streptococcal toxic shock syndrome, the tongue photographed over one admission: strawberry tongue on day three (A), crusting by day seven (B — Streptococcal toxic shock syndrome, the tongue photographed over one admission: **strawberry tongue on day three (A)**, crusting by day seven (B), shallow ulcers by day ten (C), and near-normal at discharge (D). Mucous-membrane change is part of the case definition and is often what is noticed first. **This is not the main skin sign** - that is a diffuse macular erythroderma, which no openly licensed photograph could be found for, and which on brown and black skin may not be visible at all. In a shocked patient, look at the mouth, the conjunctivae and the palms and soles rather than waiting to see a rash.
Fitzpatrick I-III (Fitzpatrick type estimated from the photograph, not stated by the source) · Takefuji H, Komagamine J, Ota K · Strawberry Tongue due to Streptococcal Toxic Shock Syndrome. Clin Case Rep 2026;14 · CC BY 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Meningococcal septicaemia and purpura fulminans — Both are febrile shock with a rash; meningococcal purpura does not blanch, TSS erythema does
Necrotising fasciitis and necrotising soft tissue infection — Not a mimic so much as a companion - streptococcal TSS and necrotising infection coexist often enough that finding one obliges you to look for the other
Staphylococcal scalded skin syndrome — Both staphylococcal toxin diseases; SSSS blisters and shears, TSS shocks
DRESS - drug reaction with eosinophilia and systemic symptoms — Both fever with widespread eruption; DRESS has weeks of latency and eosinophilia rather than shock

What to do in the ED

Resuscitate for septic shock: fluids, cultures, lactate, and early critical care involvement
Remove the source - take out the tampon, the nasal pack or the wound packing, and explore any wound
Broad-spectrum intravenous antibiotics with anti-toxin cover per local policy, and consider the need for surgical source control
Examine every soft tissue focus for disproportionate pain, because streptococcal TSS and necrotising fasciitis travel together
Take FBC, clotting, renal and liver function, CK and lactate - the diagnosis rests on multi-organ involvement
Discuss with infection services; notify public health for invasive group A streptococcal disease and arrange contact assessment
Do not wait for desquamation - it appears one to two weeks later and is a retrospective sign

Disposition

ADMIT

Resuscitation area then critical care, with infection and surgical input as the source dictates.

Sources

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