Unifying Concepts

Case Definition of Staphylococcal Toxic Shock Syndrome (TSS)

An illness with the following clinical manifestations:

  1. Fever: temperature > 38.9º C (102º F)

  2. Rash: diffuse macular erythroderma

  3. Desquamation: 1-2 weeks after onset of illness, particularly palms and soles

  4. Hypotension: systolic blood pressure < 90 mm Hg for adults or less than fifth percentile by age for children <16 years of age; orthostatic drop in diastolic blood pressure greater than or equal to 15 mm Hg from lying to sitting, orthostatic syncope, or orthostatic dizziness

Multisystem involvement: three or more of the following:

  1. Gastrointestinal: vomiting or diarrhea at onset of illness

  2. Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal for laboratory

  3. Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia

  4. Renal: blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria (greater than or equal to 5 leukocytes per high-power field) in the absence of urinary tract infection

  5. Hepatic: total bilirubin, serum glutamic-oxaloacetic transaminase (AST, SGOT), or serum glutamic-pyruvic transaminase (ALT, SGPT) at least twice the upper limit of normal for laboratory

  6. Hematologic: platelets <100,000/mm3

  7. Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent

Negative results on the following tests, if obtained:

  1. Blood, throat, or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus)

  2. Rise in titer to Rocky Mountain spotted fever, leptospirosis, or measles

Case classification

  • Probable: a case with five of the six clinical findings described above

  • Confirmed: a case with all six of the clinical findings described above, including desquamation, unless the patient dies before desquamation could occur



  1. Herzer CM. Toxic shock syndrome: broadening the differential diagnosis. J Am Board Fam Pract. 2001 Mar-Apr;14(2):131-6.[Medline]
  2. Wharton M, Chorba TL, Vogt RL, Morse DL, Buehler JW. Case definitions for public health surveillance. MMWR Recomm Rep. 1990 Oct 19;39(RR-13):1-43. [Medline]
  3. Issa NC, Thompson RL. Staphylococcal toxic shock syndrome. Suspicion and prevention are keys to control. Postgrad Med. 2001 Oct;110(4):55-6, 59-62. [Medline]


Created: Feb 23, 2006

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