Trip Answers

Question answered:11/02/08

We searched the NLH Library and the TRIP and Medline databases as well as the HPA web site but found no guidelines or studies specifically reporting the prevalence of acute toxic shock syndrome (TSS) following minor surgical procedures. Thus, we extended our search to TSS occurring postoperatively. Most of the studies we found were case reports.

 

Even extended our literature to cover all types of surgery, we found no report of the incidence of acute TSS. All the reports indicate it is a rare occurrence without quantifying the risk. For example, Strenge et al writing on orthopaedic surgery writes:

 

“Postoperative toxic shock syndrome (PTSS) after orthopedic surgery is rare, but early recognition and prompt intervention are essential to minimize morbidity and potential mortality. The diagnosis should be considered in all postoperative patients presenting with fever, hypotension, and systemic illness. The treating surgeon must have not only knowledge of the clinical entity, but also an extremely high index of suspicion, because the diagnosis can be elusive with surgical wounds appearing deceptively benign. Treatment consists of antibiotics, surgical wound debridement, and, more importantly, aggressive supportive care with intravenous fluids and intensive care surveillance. To date, the literature contains relatively few case reports of PTSS after orthopedic procedures, with even fewer cases encountered after foot and ankle surgery. This report describes a patient who developed the rare complication of PTSS after an elective ganglion cyst excision from the ankle.” [1]

 

In a second report, Fishman and Ophir state:

 

“Toxic shock syndrome (TSS) is a rare, life-threatening, acute multisystem illness usually characterized by sudden onset of high fever, diffuse sunburn-like erythroderma and a variety of other signs and symptoms. It may progress rapidly to hypotension and shock with multiple organ failure. Its exact cause is unknown, but in almost all cases there has been an infection with exotoxin-producing strains of phage group I Staphylococcus aureus. Although initially described in association with the use of superabsorbent tampons in menstruation, TSS has complicated a variety of surgical procedures. Recently in head and neck surgery attention has focused on absorbent packing materials, such as those used in postoperative nasal care. TSS developed in a 12-year-old 28 hours after tonsillectomy, nasal septoplasty and inferior turbinectomy in which absorbent packing material was used. It is important to maintain a high index of suspicion for TSS in all postoperative patients with fever, hypotension and erythroderma.” [2]

 

However, de Vries and van der Baan writing on TSS after nasal surgery states:

 

“…TSS was first reported by Todd et al. in 1978, and is a rare complication of staphylococcal infection. Although it at first was thought to be a childhood disease and an illness of menstruating women using intravaginal tampons, it has now been described as a complication of minor surgery, burns and minimal skin infections (Reingold et al., 1982; Jacobson et al., 1983). More than 2800 cases have been reported at the Centers for Disease Control (CDC) in Atlanta (Reingold, 1985). Jacobson and Kasworm (1986) estimate the incidence after nasal surgery to be 16.5 per 100.000, which in fact is higher than the incidence in women of menstrual age using intravaginal tampons. TSS usually occurs within 24-48 hours after surgery, often starting with nausea and vomiting. Although the syndrome can be lethal or can have troublesome sequelae, as prolonged weakness fatigue and neuropsychological disturbances, complete recovery is often the case.” [3]

 

Reingold et al writing in ‘The Lancet’ in 1982 notes:

 

“The 54 cases of TSS not associated with menstruation reported through the U.S.A. national surveillance system between January, 1980, and June, 1981, were either associated with Staphylococcus aureus infections (cutaneous or subcutaneous lesions, infected surgical wounds, bursitis, mastitis, adenitis, lung abscess, or primary bacteraemia) or followed childbirth by vaginal delivery and caesarean section. Patients with TSS not associated with menstruation differed significantly in age and racial distributions from those with menstruation-associated TSS, and 17 of them were male. The clinical features of TSS not associated with menstruation and the characteristics of the S. aureus strains isolated from these patients were similar to those observed in TSS related to menstruation. The median incubation period of the disease in the post-surgical cases was 2 days. TSS can occur in many clinical settings in patients of both sexes and of all ages and racial groups…” [4]

 

Graham et al undertook a retrospective review of postoperative TSS occurring in two community hospitals occurring between the years 1981-1993 and reported:

 

“We conducted a retrospective review of all cases of postoperative toxic shock syndrome (PTSS) occurring in two community hospitals from 1981-1993, during which time 390,000 surgical procedures were performed. The incidence was 0.003% (12 cases). All wounds in these 12 cases, from those with scant superficial exudates to those with gross purulence, yielded Staphylococcus aureus. All tested isolates were susceptible to methicillin or cephalothin. Patients had a mean maximal temperature of 40 degrees C. All patients had a rash, most in a truncal, "sunburn" pattern. Eleven patients had desquamation. Mean time from surgery to onset of symptoms was 4 days…” [5]

 

References
1. Strenge KB, Mangan DB and Idusuyi OB et al. Postoperative toxic shock syndrome after excision of a ganglion cyst from the ankle. J Foot Ankle Surg. 2006 Jul-Aug;45(4):275-7. (http://www.hubmed.org/display.cgi?uids=16818157
2. Fishman G and Ophir D. [Toxic shock syndrome]. Harefuah. 1997 May 1;132(9):622-4, 679. (http://www.hubmed.org/display.cgi?uids=9225573)
3. de Vries N and van der Baan S. Toxic shock syndrome after nasal surgery: is prevention possible? A case report and review of the literature. Rhinology. 1989 Jun;27(2):125-8. (http://www.hubmed.org/display.cgi?uids=2675275)
4. Reingold AL, Dan BB and Shands KN et al. Toxic-shock syndrome not associated with menstruation. A review of 54 cases. Lancet. 1982 Jan 2;1(8262):1-4. (http://www.hubmed.org/display.cgi?uids=2675275)
5. Graham DR, O'Brien M and Hayes JM. Postoperative toxic shock syndrome et al. Clin Infect Dis. 1995 Apr;20(4):895-9. (http://www.hubmed.org/display.cgi?uids=7795091)

 

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