What does TSS look like?
The clinical features of full-blown TSS are captured by the case definition ( Table 1). A minority of patients report mild prodromal symptoms. The acute illness typically begins precipitously, with high fever, nausea, vomiting, abdominal pain, severe muscle pain and tenderness, and headache, followed shortly by profuse watery diarrhoea. One or another feature of the illness may dominate the early presentation, leading to diagnostic confusion. Orthostasis or hypotension and the characteristic macular erthroderma develop over the next 48 hours. The erythroderma is usually generalised and often intense, but may be locally distributed, and may be mild or fleeting. The site of staphylococcal colonisation and toxin production may appear entirely benign.
While not accounted for by the case definition of TSS, mild systemic intoxications by the TSS toxins probably occur. These cases lack two or more of the diagnostic criteria for TSS and should not properly be called TSS. Nevertheless, they have certain features particularly suggestive of that diagnosis. Less exuberant toxin production by some strains, partial immunity in some hosts, or prompt correction of inciting conditions in some patients may explain these mild cases.