Toxic Shock Syndrome — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Suspected TSS?
   Fever + rash + hypotension + multiorgan — suspected TSS? (Superantigen-mediated (Staph aureus TSST-1 / group A Strep), massive T-cell activation → cytokine storm. Acute high fever + hypotension (may be fluid-unresponsive) + diffuse sunburn-like erythroderma + multiorgan dysfunction (renal failure, hepatic, vomiting/diarrhea, myalgia/raised CK, low platelets, altered mentation), desquamation at 1–3 weeks (a late sign, not for initial diagnosis). Triggers: menstrual (high-absorbency tampons), non-menstrual (wounds/nasal packing/streptococcal necrotizing fasciitis — pain out of proportion).)
   • Suspected TSS (fever + hypotension + multiorgan ± rash) → Suspected TSS → source control + antibiotics + IVIG
   • Does not fit → Does not fit · work up as sepsis
2. [End] Does not fit · work up as sepsis
   Evaluate other sources along the sepsis/septic shock pathway (blood/urine/CSF cultures, imaging for a focus), empiric antimicrobials + fluid resuscitation; keep a high index of suspicion for TSS (especially with a tampon/wound/streptococcal soft tissue infection, or when rash or desquamation appears).
3. [End] Suspected TSS → source control + antibiotics + IVIG
   Source control — remove a tampon/nasal packing/foreign body, drain/debride the infected focus (streptococcal necrotizing fasciitis → emergency surgical debridement). Aggressive fluid resuscitation + vasopressors (per the sepsis bundle) + ICU organ support. Empiric antibiotics: MRSA cover (vancomycin/linezolid) + clindamycin (suppresses toxin/superantigen synthesis), add penicillin for streptococcal; IVIG to neutralize the superantigen (especially streptococcal/refractory).

Source guidelines & references

• Toxic shock syndrome (CDC clinical criteria; IDSA; AMBOSS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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