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Toxic Shock Syndrome Micro Exam 6 (Staph aureus Nose:nose::skin-tone…

- - - - Epidermolytic Toxin A
        chromosome
        (carried on)
      - Epidermolytic Toxin B
        plasmid
        (carried on)
        
        more frequently isolated
        
        related to multiple copies of plasmid
        
        more mRNA
        
        more protein
      - Acantholysis below or within Stratum Granulosum of epidermis
        
        Does NOT distrupt dermis/mucous membranes
        
        :!: SAME TOXIN
        
        Differentiate from:
        
        Toxic Epidermal Necrosis / Stephen Johnson Syndrome
        
        Meds trigger separation between epidermis & dermis
        
        Extensive necrosis & detachment epidermis
    - - Early Stage
        
        Fever
        
        Irratibility
        
        Purulent rhinorrhea
        
        Difuse blanching erythema ( :woman::skin-tone-2: begins at face esp. :lips:)
      - Acute Stage (24-28 h)
        
        Rash progresses - scarlatiniform blistering eruption
        
        Mucous membranes spared (like TSS)
        
        Conjunctivitis
        
        Tissue paper like wrinkling of epidermis
        
        Large flaccid bullae/blisters form (mechanical stress areas)
        - Nikolsky's sign
        
        press finger on skin --> separation of upper epidermis
        
        Diffuse, sheet-like desquamation (up to 5 days)
        
        Denuded skin w/ scalded skin :fire: think: BURN patient
        
        Erythematous base
        
        Crusting on skin esp. at mouth :lips:(also seen in impetigo)
        
        NO S.aureas present!
        
        Lesions heal w/ no scarring (up to 2 wks)
        Cleavage plane is intraepidermal (stratum granulosum)
        adults freq. have bacteremia & pneumonia follow
  - - - TSST-1
        *common in menstral & nonmenstral
        
        Regulated & Increased with:
        
        Increased PO2
        
        Increase pH (from 4 to 7)
        
        Decrease free Mg
      - Staph Enterotoxin B (SEB)
        food poisoning
      - Staph Enterotoxin A (SEA)
        cofactor w/ TSST-1
    - - Fever
        
        102F or >38.9C
      - Skin Changes
        
        A. Diffuse macular erythroderma
        
        B. Desquamation
        1-2 weeks after
        Palms & soles in surviving pt
      - Hypotension/Shock
        
        Adult SBP </= 90
        
        Kid SBP <5th percentile by height
        
        Orthostatic syncope
      - Multisystem Involvement
        :three: or more
        
        CNS (disorentation/confusion)
        
        Hematologic (Platelets <100,000)
        
        Mucous Membrane Hyperemia (excess blood in conjunctiva, oropharyngeal, vaginal) :explode:staph only! not strep
        
        Severe myalgia (muscle)
        
        GI (vomiting/diarrea at onset) = SEA-C
        
        Liver (elevated bilirubin, transaminases)
        
        Renal (elevated BUN, creatinine; urinary sedement w/ pyuria)
        
        Mucous Membrane Hyperemia (=conjunctival suffusion)
        Additional cause: Leptospirosis from spirochete
    - - Case Classification:
        
        Confirmed:
        
        Meets lab criteria
        
        5/5 clinical manifestations
        
        Probable:
        
        Meets lab criteria
        
        4 or 5 clinical manifestations
        
        DO NOT EXCLUDE SUSPICIOUS TSS CASE EVEN IF NO CRITERIA MET
        (can be difficult to Dx)
- - - - Risk Factors:
        
        DM
        
        Alcoholism
        
        Minor trauma
        
        Injuries (hematoma, bruising, muscle strain) expose vimentin
        
        Surgery
        
        Viral infections
        
        Varicella (KIDS)
        
        NSAIDS (affects renal clearance)
    - - Strep Pyrogenic Exotoxins (SPE)
        SPE A (US)
        SPE B (Sweden/UK)
        
        Cytotoxicity, pyrogenicity, enhances endotoxin
        
        Produces massive cytokine storm
      - Streptolysin O
        
        synergist w/ SPE A
        
        TNF & IL-1 production
      - M Type Protein (1, 3, 12, 28)
        
        Creates more virulent GAS strain
        
        Antiphagocytic properties
      - Mucoid Colonies
        
        Hyaluronic capsules (very thick)
      - Streptococcal Superantigen (SSA)
      - Mitogenic Factor (MF)
        
        Make unsensitized leukocytes
    - - Isolate GAS from normally sterile site
        
        blood
        
        CSF
        
        pleural/peritoneal fluid
        
        tissue biopsy
        
        surgical wound
      - Hypotension (like Staph TSS)
      - Multiorgan Involvment
        :two: or more
        
        Coagulopathy (thrombocytopenia, DIC)
        
        Erythematous macular rash (may desquamate)
        
        Soft tissue necrosis (necrotizing fasciitis, myositis, gangrene)
        
        Lungs: ARDS
        
        Liver dysfunction (transaminase, bilirubin eleveated)
        
        Renal dysfunction