1. Toxic Shock Syndrome Tamer Shalaby, ST5 Acute Medicine RSCH, United Kingdom 1. Brosnahan AJ and Schlievert PM; Gram-positive bacterial superantigen outside-in signalling causes toxic shock syndrome, FEBS journal 278 2011;4649-4667 2. Matsuda Y et al; Diagnosis of toxic shock syndrome by two different systems; clinical criteria and monitoring of TSST-1-reactive T cells;Microbiol Immunol 2008; 52:513-521 3. Hackett SP and Stevens DI; Streptococcal Toxic Shock Syndrome: Synthesis of Tumor Necrosis Factor and Interleukin-1 by Monocytes Stimulated with Pyrogenic Exotoxin A and Streptolysin O; The Journal of Infectious Diseases 1992;165:879-85 4. Dellaripa PF; Toxic Shock Syndrome; Journal of Intensive Care Med 2000;15:314-320 5. Hajjeh RA, Reingold A, Weil A, et al.Toxic shock syndrome in the United States: surveillance update, 1979 to 1996. Emerg Infect Dis 1999;5:807 810 6. Darenberg J et al; Intravenous Immunoglobulin G Therapy in Streptococcal Toxic Shock Syndrome: A European Randomized, Double-Blind, placebo-Controlled Trial; Clinical Infectious Diseases 2003;37:333-40 7. Melish ME, Frogner K, Hirata S, et al. Use of IVIG for therapy in the rabbit model of TSS [abstract]. Clin Res 1987;35:220A 8. http://medchrome.com/wp-content/uploads/2010/12/TSS-pathogenesis.jpg Discussion: Strains of s. aureus producing TSST-1 which is a superantigen that interact with T Cells to induce massive cytokine production including TNF-alpha, TNF- Beta, (IL-1, IL-2, IL-6) 1-3. Vaginal colonisation followed by penetration of a sufficient concentration of TSST-1 across the epithelium; abrasion from tampon use. Fever >38.9, GIT disturbance, macular erythema involving palms and soles, mucous membrane hyperaemia 4.Hypotension with MOF occurs usually within 72 hours with significant mortality rate 5. Clindamycin is superior to penicillin because of its potency in suppressing bacterial toxin synthesis 16. (IVIG) therapy has showed anti TSST-1 effect 6, 7. TSS: toxic shock syndrome, TSST-1: toxic shock syndrome toxin, MOF: multiple organ failure, C+S: culture and sensitivity, A&E: accident and emergency, BP: blood pressure, s. aureus: staphylococcus aureus, TNF: tumor necrosis factor, IVIG: intravenous immunoglobulins, ICU: intensive care unit, interleukin (IL) Case Presentation: 45 year old female presented to A&E been generally unwell for the past 12 hours. On prednisolone and mycophenolate mofetil for an autoimmune disease. Normal examination save temperature of 39.7°C and tachycardia at 110. Tazocin and fluid resuscitation given. However, Two hours later her systolic BP reduced to 60. Nursing staff reported that there was a tampon with green discharge – which grew s. aureus later but negative blood C+S. In ICU she was started on meropenem, clindamycin and IVIG. Required high doses of noradrenaline and Vasopressin after aggressive fluid resuscitation; subsequently haemofiltration after hours of oliguria and worsening renal function. Good recovery after 7 days. Learning Points: High index of Suspicion of S. Aureus TSS in menstruating ladies with tampons who present with febrile illness with no obvious source of infection. Hypotension and MOF occur within hours TSS may be resistant to aggressive fluid and antibiotic therapy. Blood (C+S) is negative in TSS. The role for clindamycin and IVIG References Key Words