2.2.7 Staphylogenic/Streptogenic Toxin Shock-Syndrom (STSS)

Grading & Level of Importance: C




Menstrual and non-menstrual STSS. 


STSS: about 50 cases per year in US. 


STSS: acute S.aureus toxin TSST-1 and enterotoxins related disease with fever, myalgia, nausea, headache and vomiting and diffuse macular erythema followed by erythroderma and later exfoliation. 

Aetiology & Pathogenesis

Toxin-mediated epidermolytic dermatosis, characterized by erythema and widespread loss of the superficial epidermal layers, resembling burn.  STSS menstrual type toxin TSST-1 and enterotoxins SEA to SEO . Non-menstrual type toxin is related to S.aureus colonies from several infections. 

Signs & Symptoms

Following a staphylococcal or streptococcal infection, initially erythema resembling scarlet fever followed by small unstable blisters which quickly erode and lead to widespread skin loss similar to grade II burns. Acute course, systemically ill patient. Nikolski sign positive. 


All areas.


Menstrual and non-menstrual STSS. 

Laboratory & other workups

Intensive care laboratory data regarding kidney, liver and blood, albumin. 


Acantholytic cleft in the S.granulosum and blister roof only contains stratum corneum (in contrast to TEN with full-thickness epidermal damage), subcorneal blisters and bullae. 


Rapid onset within hours to two days. 


Sepsis, pneumonia. In STSS high mortality. 


History, clinical feature, histology (frozen section of blister roof). 

Differential diagnosis

TEN (drug--induced), epidermolysis bullosa, chronic bullous disease of childhood (linear IgA disease). Staphylococcal scalded syndrome (SSSS); Kawasaki syndrome. 

Prevention & Therapy

Patients are to be admitted immediately to intensive care unit. Antibiotics covering resistant staphylococci or streptococci according to resistogram; immunoglobulins are recommended. Fluid replacement as in burn patients, elimination of bacterial foci; antimicrobial disinfectant therapy (baths, compresses). Paracetamol, no NSAIDs. 


Immediate biopsy for cryosection to visualize the location of blister for differential diagnosis. 

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