When should the diagnosis of TSS be considered?
The differential diagnosis of the patient acutely ill with fever, rash and hypotension is extensive (Table 3). A careful history with attention to past health, possible infectious exposures, travel, vocation, hobbies, vaccination status, menstrual status and medication usage often narrows the diagnostic possibilities considerably.
Consider TSS in:
1) Any patient with fever and hypotension, whether exanthem is obvious or inapparent, especially if an alternative diagnosis is not readily apparent.
Suggestive epidemiological settings include:
- Females who are either menstruating or postpartum
- Females using barrier contraceptives
- Postoperative patients
- Patients with varicella or Herpes zoster infection
- Patients with chemical or thermal burns
Laboratory findings consistent with TSS include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria. Each is present in greater than 70 percent of patients.
2) The less ill patient with suggestive symptoms who fails to meet diagnostic criteria, but who is in an epidemiological risk group. For example, consider the possibility of mild systemic staphylococcal intoxication in young women reporting substantial or recurrent perimenstrual flu-like illness, particularly if that illness is associated with erythroderma or desquamation. Of course, the great majority of women experiencing nonspecific perimenstrual symptoms have syndromes unrelated to TSS or the staphylococcal toxins.