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Potentially life-threatening emergency
Toxic shock syndrome in Infant/Neonate
Other Resources UpToDate PubMed
Potentially life-threatening emergency

Toxic shock syndrome in Infant/Neonate

Contributors: Elizabeth Bisbee MD, Craig N. Burkhart MD, Dean Morrell MD, Paritosh Prasad MD, Susan Burgin MD
Other Resources UpToDate PubMed


Toxic shock syndrome (TSS) is a severe exotoxin-mediated bacterial infection that is characterized by the acute onset of high fever, headache, conjunctival injection, erythema of the pharynx, vomiting, diarrhea, and hypotension. Two subtypes of TSS exist, based on the bacterial etiology: Staphylococcus aureus and group A streptococci. Significantly, the severity of TSS can range from mild disease to rapid progression to shock and end organ failure.

Children are most susceptible to TSS between the ages of 6 months and 2 years. Before 6 months, the mother's antibodies are protective, and after age 2 years, the child begins producing antibody titers in higher amounts. TSS mortality rates are much lower in children than adults, at 5%-10% and 3%-5% for streptococcal versus staphylococcal types, respectively.

Note: An increase in invasive S pyogenes (invasive group A streptococcal [iGAS]) infections in children, including necrotizing fasciitis and streptococcal TSS, has been reported in Europe and the United States in 2022-2023.

TSS may result from surgical wounds, burns, or any other type of mucous membrane, skin, or soft tissue infection with S aureus. If the US Centers for Disease Control (CDC) criteria are strictly followed, TSS is extremely rare in infants (refer to Diagnostic Pearls section for CDC definition of staphylococcal TSS). Partial expression may be due to passive immunity conferred by maternal antibodies during the first 3-6 months of life, the increased tolerance of infantile T cells to superantigens, and early treatment leading to a blunted course. Names for these partial expressions of toxin-mediated disease include neonatal toxic shock syndrome-like exanthematous disease (NTED) and staphylococcal toxemia.


A48.3 – Toxic shock syndrome

18504008 – Toxic shock syndrome

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Differential Diagnosis & Pitfalls

  • Staphylococcal scalded skin syndrome
  • Kawasaki disease – Fever lasting for more than 5 days with oral mucosal changes, conjunctival injection, and cervical lymphadenopathy.
  • Multisystem inflammatory syndrome in children from COVID-19
  • Scarlet fever – 1-mm erythematous papules, always elevated WBC with left shift, eosinophilia in up to 20% of patients.
  • Drug-induced hypersensitivity syndrome (DRESS)
  • Exanthematous drug eruption
  • Erythroderma
  • Toxic epidermal necrolysis (TEN)
  • Stevens-Johnson syndrome (SJS)
  • Allergic contact dermatitis
  • Juvenile pityriasis rubra pilaris
  • Sezary syndrome (see Cutaneous T-cell lymphoma)
  • Erysipelas
  • Necrotizing fasciitis – Rapidly progressing necrosis of fascia and subcutaneous fat.
  • Acute meningococcemia – Rapid decompensation, characteristic petechial eruption caused by Neisseria meningitidis.
  • Rocky Mountain spotted fever – Characteristic retiform purpura; check for serologies.

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Last Reviewed:02/26/2022
Last Updated:04/06/2023
Copyright © 2024 VisualDx®. All rights reserved.
Potentially life-threatening emergency
Toxic shock syndrome in Infant/Neonate
A medical illustration showing key findings of Toxic shock syndrome : Diarrhea, Fever, Headache, Hypotension, Vomiting, ALT elevated, AST elevated, Creatinine elevated, Edema, Erythroderma, Tachycardia, Widespread distribution, Myalgia, Confusion
Clinical image of Toxic shock syndrome - imageId=2937697. Click to open in gallery.  caption: 'Deep red shiny patches and plaques on the palm and fingers.'
Deep red shiny patches and plaques on the palm and fingers.
Copyright © 2024 VisualDx®. All rights reserved.