Toxic shock syndrome (TSS) with acute respiratory distress syndrome (ARDS): A deadly combo

A 23-year-old man presented with high-grade fever, generalized rash (Fig. 1a) and shortness of breath for 3 days. He was drowsy, tachycardic and hypotensive with an oxygen saturation of 86%. Chest X-ray showed diffuse air space opacities (Fig. 2a) followed by chest computed tomography (CT) scan showing bilateral peribronchovascular ground glass opacities suggesting an acute respiratory distress syndrome (ARDS) (Fig. 2b). A right subareolar abscess with a discharging sinus was also noticed (Fig. 1b). A bedside Gram-stain of the pus aspirated showed Gram-positive cocci in clusters (Fig. 1c) and subsequently the pus and the blood culture grew methicillin-resistant Staphylococcus aureus (MRSA). With this microbiological background and a clinical picture of rash, hypotension with multi-organ dysfunction in an otherwise healthy young adult, a strong suspicion of toxic shock syndrome (TSS) was made, which was confirmed as per the CDC case definition 2011 criteria.¹

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FIG 1.

(a) Image showing erythematous, maculopapular rash over right lower limb of the patient (the rash involved all four limbs, trunk but face, palm and sole were spared); (b) image showing right subareolar abscess (red arrow); (c) a bedside Gram-stain of pus discharge from the right subareolar abscess showing Gram-positive cocci in clusters (blue arrow).

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FIG 2.

(a) Chest X-ray showing bilateral air-space opacities; (b) axial CT scan of chest showing bilateral symmetrical peribronchovascular ground glass opacities and interlobular septal thickening suggesting ARDS

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TSS is a medical emergency, presenting as acute illness with fever, generalized rash, shock and multi-organ dysfunction.² It is a rare, yet a lethal exotoxin (TSST-1 or related toxin) mediated disease caused by Staphylococcus or Streptococcus. The exotoxin acts as a super antigen indiscriminately activating large populations of T cells leading to cytokine storm and end-organ damage.³ Initially described in menstruating women (using tampons), now more than half of TSS cases are seen in conditions such as cellulitis, abscesses, postpartum infections, postsurgical procedures, etc.⁴ Staphylococcus TSS can rarely lead to atypical manifestations such as frank ARDS. High level of clinical suspicion and prompt initiation of appropriate treatment is of paramount importance.