Non-menstrual toxic shock syndrome – cases reported to the National Reference Laboratory for Staphylococci, Centre for Epidemiology and Microbiology, National Institute of Public Health, 1983–2025
Authors:
J. Bílý; H. Kmječová; J. Kseničová; P. Petráš
Authors‘ workplace:
Národní referenční laboratoř pro stafylokoky, Centrum epidemiologie a mikrobiologie, Státní zdravotní ústav, Praha
Published in:
Epidemiol. Mikrobiol. Imunol. 75, 2026, č. 2, s. 66-70
Category:
Original Papers
doi:
https://doi.org/10.61568/emi/11-6717/20260323/143209
Overview
Objective: To identify the virulence factors responsible for toxic shock syndrome in causative strains submitted by field laboratories throughout the Czech Republic. Methods: To detect the production of TSST-1 and staphylococcal enterotoxins, the micro-slide gel diffusion test was initially used and later followed by reverse passive latex agglutination. Currently, the polymerase chain reaction is the preferred tool for the detection of toxin genes as well as genes for other toxins of S. aureus strains: exfoliatins A, B, and D, Panton-Valentine leukocidin, and the mecA and mecC genes responsible for resistance to methicillin/cefoxitin and other beta-lactam antibiotics. A simple form was used to obtain information which confirmed the diagnosis of toxic shock syndrome (A48.3). Results: Over a 42-year period from 1983 to 2025, the toxinogenicity of the causative agent was confirmed in 174 cases of non-menstrual toxic shock syndrome. The TSST-1 toxin (either alone or in combination with enterotoxin) was produced by 60% of the strains studied. Only 40% of the strains were positive for a specific type of enterotoxin. Most strains were methicillin-sensitive, and seven strains (4.0%) were positive for the mecA gene. Genes for Panton-Valentine leukocidin were detected in a single strain. The most common type of staphylococcal infection leading to toxic shock syndrome was pyoderma. Other cases were associated with hospital acquired and post-traumatic wound infections. Of the entire cohort, the disease resulted in death of 38 patients, representing a high case fatality rate of 21.8%. Conclusion: Toxic shock syndrome is a serious staphylococcal disease affecting multiple organs, which can be fatal in severe cases. Given the wide range of symptoms, establishing a clinical diagnosis can sometimes be difficult. It is crucial to recognize the staphylococcal toxin aetiology and initiate early appropriate treatment.
Keywords:
Staphylococcus aureus – toxic shock syndrome – TSST-1 – staphylococcal enterotoxin
Sources
1. CDC. Staphylococcal Toxic Shock Syndrome case definition 2011. Dostupné na www: https://ndc.services.cdc.gov/case-definitions/toxic-shock-syndrome-2011/.
2. CDC. Clinical criteria for staphylococcal toxic shock syndrome (TSS) UpToDate 2022. Dostupné na www: https://www.uptodate.com/contents/image?imageKey=ID%2F54778.
3. Mašata J, Jedličková A. a kol. Infekce v gynekologii a porodnictví. Maxdorf 2004, ISBN 80-7345-038-0.
4. Petráš P, Prusík F, Nyč O, Machová I. Nemocniční kmeny MRSA s negativním clumping-faktorem. Zprávy CEM (SZÚ, Praha). 2005;14(3):122–124.
5. Martineau F, Picard F, Roy P. Species-specific and ubiquitous - -DNA-based assay for rapid identification of Staphylococcus aureus. J Clin Microbiol., 1998;36 : 618–623. PMID: 9508283 DOI: 10.1128/JCM.36.3.618-623.1998.
6. Hallander HO. Purification of staphylococcal enterotoxin B. Acta Pathol Microbiol Scand. 1966;67 : 117–132. PMID: 5959079 DOI: 10.1111/apm.1966.67.1.117.
7. Wieneke AA. The detection of enterotoxin and toxic shock syndrome toxin – 1 by strains of Staphylococcus aureus with commercial RPLA kits. Int J Food Microbiol. 1988;(1):25–30. PMHID: 3275307 DOI: 10.1016/0168-1605(88)9069-4.
8. Lovseth A, Loncarevic S, Bergal K. Modified multiplex PCR method for detection of pyrogenic exotoxin genes in staphylococcal isolates. J Clin Microbiol., 2004;42 : 3689–3872. PMID: 15297552 DOI: 10.1128/JCM.42.8.3869-387.2004
9. Fischer A, Francois P, Holtfreter S. Development and evaluation of a rapid strategy to determine enterotoxin gene content in Staphylococcus aureus. J Microbiol Meth., 2009;77 : 184–190. PMID: 19318048 DOI: 10.1016/j.mimet.2009.01.022.
10. Lina G, Piemont Y, Godail-Gamot F, et al. Involvement of Panton-Valentine Leukocidin-Producing Staphylococcus aureus in primary skin infections and pneumonia. Clin Inf Diseases, 1999;29 : 1128–1132. PMID: 10524952 DOI: 10.1086/313461.
11. Ruzickova V, Voller J, Pantucek R, Petras P, Doskar J. Multiplex PCR for Detection of Three Exfoliative Toxin Serotype Genes in Staphylococcus aureus. Folia Microbiol. 2005;50(6):499–502. PMID: 16681147 DOI: 10.1007/BF02931437.
12. Geha DJ, Uhl JR, Gustaferro CA, Persing DH. Multiplex PCR for identification of methicillin-resistant staphylococci in clinical laboratory. J Clin Microbiol. 1994;32 : 1768–1772. PMID: 7929772 DOI: 10.1128/jcm.32.7.1768-1772.1994.
13. Petráš P, Šimková M, Kekláková J, Hutníková R, Bílý J. Cases of menstrual toxic shock syndrome in the Czech Republic in 1997–2022. Medical Journal of Obstetrics and Gynecology. 2023;11(2):1173. DOI: 10.47739/2333-6439.obstetrics.1173
14. Deseloux E, Perpoint T, Ferry T, Lina G, Bes M, Vandenesch F, Mohammedi I, Etienne J. One in five mortality in non-menstrual toxic shock syndrome versus no mortality in menstrual cases balanced French series of 55 cases. Eur J Clin Microbiol Infect Dis., 2008;27 : 37–43. PMID: 17932694 DOI: 10.1007/s10096-007 - 0405-2.
15. Crass BA, Bergdoll MS. Involvement of staphylococcal enterotoxins in non-menstrual toxic shock syndrome. J Clin Microbiol. 1986;23(6):1138–1139. PMID: 3711305 DOI: 101128/ jcm.23.6.1138-1139.1986.
16. Jarraud S, Coyon G, Vandenesch F, et al. Involvement of enterotoxins G and I in staphylococcal toxic shock syndrome and staphylococcal scarlet fever. J Clin Microbiol. 1999;37(8):2446–2449. PMID: 10405382 DOI: 10.1128/JCM.37.8.2446-2449.1999.
17. Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal surgery: Case reports and analysis of risk factors. Arch Otolaryngol Head Neck Surg. 1986;112(3):329–332. PMID: 3942641 DOI: 10.1001/archotol.1986.03780030093019.
18. Tyll T, Bilková M, Revinová A, et al. Syndrom toxického šoku. Epidemiol microbiol imunol. 2015;64(4):210–220. PMID: 26795225.
19. Bílý J, Micherová J, Kopecká M., Ryšková L, Petráš P. Syndrom toxického šoku stafylokokového původu u popálenin – výsledky NRL pro stafylokoky. Zprávy CEM (SZÚ, Praha). 2025;34(9):303 – 306.
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Hygiene and epidemiology Medical virology Clinical microbiologyArticle was published in
Epidemiology, Microbiology, Immunology
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