Toxic shock syndrome is an acute, multi-system, toxin-mediated illness, often resulting in multi-organ failure, that represents the most fulminant expression of disease caused by toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes (group A streptococcus) [2]. Pathogenetically, bacterial superantigenic exotoxins—including TSST-1 and staphylococcal enterotoxins, and streptococcal pyrogenic exotoxins A, B, C and streptococcal superantigen A—stimulate immune-cell expansion and cytokine release in a non–MHC-restricted manner, producing a cytokine avalanche that causes tissue damage, disseminated intravascular coagulation, and organ dysfunction [1][2]. Streptococcal TSS is sometimes referred to as toxic-shock-like syndrome (TSLS) [3].
Disease overview
BacterialToxic shock syndrome
中毒性休克综合征
Toxic shock syndrome (TSS) is a rare, acute, life-threatening, toxin-mediated infectious process that results from superantigenic exotoxins produced mainly by Staphylococcus aureus or Streptococcus pyogenes (group A streptococcus), triggering massive polyclonal lymphocyte activation and a cytokine cascade that rapidly progresses to shock and multi-organ failure [1][2]. It exists in staphylococcal (menstrual or nonmenstrual) and streptococcal forms, with streptococcal TSS most frequently linked to severe invasive group A streptococcal disease such as necrotizing soft-tissue infection [1]. Reported overall mortality is approximately 5% for staphylococcal disease and 50% for streptococcal disease, and death may occur within two days [3]. TSS is considered a medical emergency requiring early recognition, resuscitation, source control, and antimicrobial therapy [1][2].
Read the full clinical and epidemiological profile4
Clinical features vary somewhat between staphylococcal and streptococcal forms. Staphylococcal TSS typically begins with influenza-like symptoms of fever, vomiting, diarrhea, and severe myalgia, followed rapidly by hypotension; a characteristic rash appears early on the trunk and spreads to the extremities, with desquamation one to three weeks after onset, and blood cultures are positive in fewer than 5% of cases because illness is driven by toxin production rather than bacteremia [1][2][3]. Streptococcal TSS commonly presents with severe localized pain as the earliest and most prominent feature, along with fever, sore throat, and gastrointestinal upset, with soft-tissue infections as a frequent source and no identifiable entry site in up to half of cases; blood cultures are positive in 60–80%, and a scarlatiniform rash may occur but is less common than the erythroderma seen in staphylococcal disease [3]. General manifestations across forms include shock, rash, skin peeling, and multi-organ failure, with additional features reflecting the underlying infection such as mastitis, osteomyelitis, necrotising fasciitis, or pneumonia [1][3]. Clindamycin treatment has been associated with reduced mortality in streptococcal TSS, and intravenous immunoglobulin in addition to clindamycin has been linked to a fall in mortality from 33.7% to 15.7% across one randomized and four nonrandomized studies, although certainty of evidence is low [4][5].
TSS is described as rare, with the published literature dominated by observational studies, clinical cases, and in vitro data, and additional studies are difficult to conduct because of the low incidence [1].
- 1Atchade E et al. Toxic Shock Syndrome: A Literature Review. Antibiotics (Basel). 2024 Jan 18. PMID: 38247655. doi: 10.3390/antibiotics13010096.PubMed: https://pubmed.ncbi.nlm.nih.gov/38247655/
- 2Lappin E et al. Gram-positive toxic shock syndromes. Lancet Infect Dis. 2009 May. PMID: 19393958. doi: 10.1016/S1473-3099(09)70066-0.PubMed: https://pubmed.ncbi.nlm.nih.gov/19393958/
- 3Wikipedia contributors. Toxic shock syndrome - Wikipedia [Internet]. Wikipedia. cited 3 Sept 2026.Available from: https://en.wikipedia.org/wiki/Toxic_shock_syndrome
- 4Bartoszko JJ et al. Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis. BMJ Open. 2022 Dec 1. PMID: 36456018. doi: 10.1136/bmjopen-2022-063023.PubMed: https://pubmed.ncbi.nlm.nih.gov/36456018/
- 5Parks T et al. Polyspecific Intravenous Immunoglobulin in Clindamycin-treated Patients With Streptococcal Toxic Shock Syndrome: A Systematic Review and Meta-analysis. Clin Infect Dis. 2018 Oct 15. PMID: 29788397. doi: 10.1093/cid/ciy401.PubMed: https://pubmed.ncbi.nlm.nih.gov/29788397/
Data access
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