
Health Dictionary
Reliable, easy-to-read patient information on common medical conditions β written in plain language, free of jargon, and grounded in current evidence. Browse the most frequent diagnoses, understand what they mean for everyday life, and learn which steps and questions help you have a focused conversation with your doctor.
Toxic shock syndrome differential diagnosis
Introduction

Overview
Overview
Toxic shock syndrome (TSS) may have a similar presentation to some diseases which present as a rash, fever and hypotension. Some features are unique to toxic shock syndrome and can be used to differentiate it from other diseases.
Differentiating Toxic Shock Syndrome from other Diseases
Differentiating Toxic Shock Syndrome from other Diseases
Toxic shock syndrome requires all 3 manifestations ofΒ fever, hypotension and diffuse scarlatiniform rash (innumerable small red papules that are diffusely distributed plus erythema, which blanches and desquamates one or two weeks after onset of illness). It presents with various signs of infection, hemodynamic dysfunction and organ failure.
Clinical presentation of fever, hypotension and rash must be differentiated from other diseases like:
- Meningococcemia
- Steven Johnson syndrome (SJS)
- Toxic epidermal necrolysis (TEN)
- Scarlet fever
- Red man syndrome
- Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
Clinical presentation of fever and rash must be differentiated from other diseases like:
- Viral exanthem
- Rickettsial disease
- Kawasaki disease
- Staphylococcal scalded skin syndrome
- Exfoliative erythroderma syndrome
- Erythema multiforme major
Differential Diagnoses in Patients with Fever, Hypotension and Rash
| Disease | Epidemiology | Predisposing factors | Clinical features[1][2][3] | Lab abnormalities | ||||
|---|---|---|---|---|---|---|---|---|
| Signs | Symptoms | |||||||
| Toxic shock syndrome | Occurs in both adults and children (9:1 female predominance) |
|
Fever | Hypotension | Diffuse Rash | Other signs |
|
|
| + | + | + |
| |||||
| Meningococcemia | Occurs in young adults living in close proximity (college dorms, military recruits)[13] |
|
+ | + | + |
|
| |
| Stevens Johnson syndrome (SJS) | HLA-B*1502 gene leads to increased susceptibility[18] | Triggered by certain medications, most commonly: | + | + | + |
|
| |
| Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome | + | + | + |
|
|
| ||
| Red man syndrome | Patients in whom the offendingΒ drug infusion is given over less than 1 hour and who are not pre-treated with diphenhydramine[28] | Hypersensitivity to:[29] | + | + | + |
|
|
No elevation in tryptase levels indicating that it is an anaphylactoid reaction[30] |
| Kawasaki | Occurs in children, usually age 1-4 years |
|
+ | + | + |
|
|
|
| Scarlet fever | Distributed equally among both genders. Most commonly affects children between five and fifteen years of age. | Occurs after streptococcal pharyngitis/tonsillitis | + | +/- | + |
|
Rash:
|
|
Common Differential Diagnoses in Patients with Fever and Rash
| Disease | Features |
|---|---|
| ImpetigoΒ | |
| Insect bites |
|
| Measles |
|
| Monkeypox |
|
| Rubella |
|
| Atypical measles |
|
| Coxsackievirus |
|
| Acne |
|
| Syphilis | It commonly presents with gneralized systemic symptoms such as malaise, fatigue, headache and fever. Skin eruptions may be subtle and asymptomatic It is classically described as:
|
| Molluscum contagiosum |
|
| Mononucleosis |
|
| Toxic erythema | |
| Rat-bite fever | |
| Parvovirus B19 | |
| Cytomegalovirus |
|
| Scarlet fever |
|
| Rocky Mountain spotted fever |
|
| Varicella-zoster virus | |
| Chickenpox |
|
| Rickettsial pox | |
| Meningitis |
|
References
References
- β Todd JK (1988). “Toxic shock syndrome”. Clin. Microbiol. Rev. 1 (4): 432β46. PMCΒ 358064. PMIDΒ 3069202.
- β Kang JH (2015). “Febrile Illness with Skin Rashes”. Infect Chemother. 47 (3): 155β66. doi:10.3947/ic.2015.47.3.155. PMCΒ 4607768. PMIDΒ 26483989.
- β Sivagnanam S, Deleu D (2003). “Red man syndrome”. Crit Care. 7 (2): 119β20. PMCΒ 270616. PMIDΒ 12720556.
- β McGregor JA, Soper DE, Lovell G, Todd JK (1989). “Maternal deaths associated with Clostridium sordellii infection”. Am. J. Obstet. Gynecol. 161 (4): 987β95. PMIDΒ 2801850.
- β “Clostridium sordellii toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol–United States and Canada, 2001-2005”. MMWR Morb. Mortal. Wkly. Rep. 54 (29): 724. 2005. PMIDΒ 16049422.
- β Fischer M, Bhatnagar J, Guarner J, Reagan S, Hacker JK, Van Meter SH, Poukens V, Whiteman DB, Iton A, Cheung M, Dassey DE, Shieh WJ, Zaki SR (2005). “Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion”. N. Engl. J. Med. 353 (22): 2352β60. doi:10.1056/NEJMoa051620. PMIDΒ 16319384.
- β Sinave C, Le Templier G, Blouin D, LΓ©veillΓ© F, Deland E (2002). “Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease”. Clin. Infect. Dis. 35 (11): 1441β3. doi:10.1086/344464. PMIDΒ 12439811.
- β Ho CS, Bhatnagar J, Cohen AL, Hacker JK, Zane SB, Reagan S, Fischer M, Shieh WJ, Guarner J, Ahmad S, Zaki SR, McDonald LC (2009). “Undiagnosed cases of fatal Clostridium-associated toxic shock in Californian women of childbearing age”. Am. J. Obstet. Gynecol. 201 (5): 459.e1β7. doi:10.1016/j.ajog.2009.05.023. PMIDΒ 19628200.
- β Kang JH (2015). “Febrile Illness with Skin Rashes”. Infect Chemother. 47 (3): 155β66. doi:10.3947/ic.2015.47.3.155. PMCΒ 4607768. PMIDΒ 26483989.
- β Brook MG, Bannister BA (1988). “Scarlet fever can mimic toxic shock syndrome”. Postgrad Med J. 64 (758): 965β7. PMCΒ 2429080. PMIDΒ 3256819.
- β Minemura M, Tajiri K, Shimizu Y (2014). “Liver involvement in systemic infection”. World J Hepatol. 6 (9): 632β42. doi:10.4254/wjh.v6.i9.632. PMCΒ 4179142. PMIDΒ 25276279.
- β Chesney RW, Chesney PJ, Davis JP, Segar WE (1981). “Renal manifestations of the staphylococcal toxic-shock syndrome”. Am. J. Med. 71 (4): 583β8. PMIDΒ 7282746.
- β Harrison LH (2010). “Epidemiological profile of meningococcal disease in the United States”. Clin. Infect. Dis. 50 Suppl 2: S37β44. doi:10.1086/648963. PMCΒ 2820831. PMIDΒ 20144015.
- β MacLennan J, Kafatos G, Neal K, Andrews N, Cameron JC, Roberts R, Evans MR, Cann K, Baxter DN, Maiden MC, Stuart JM (2006). “Social behavior and meningococcal carriage in British teenagers”. Emerging Infect. Dis. 12 (6): 950β7. PMCΒ 3373034. PMIDΒ 16707051.
- β WARTENBERG R (1950). “The signs of Brudzinski and of Kernig”. J. Pediatr. 37 (4): 679β84. PMIDΒ 14779273.
- β Bush LM (2014). “Case 28-2014: A man with a rash, headache, fever, nausea, and photophobia”. N. Engl. J. Med. 371 (23): 2238β9. doi:10.1056/NEJMc1412237#SA2. PMIDΒ 25470712.
- β “Meningitis Symptoms – Meningitis Research Foundation”.
- β Chung WH, Hung SI, Hong HS, Hsih MS, Yang LC, Ho HC, Wu JY, Chen YT (2004). “Medical genetics: a marker for Stevens-Johnson syndrome”. Nature. 428 (6982): 486. doi:10.1038/428486a. PMIDΒ 15057820.
- β Techasatian L, Panombualert S, Uppala R, Jetsrisuparb C (2016). “Drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in children: 20 years study in a tertiary care hospital”. World J Pediatr. doi:10.1007/s12519-016-0057-3. PMIDΒ 27650525.
- β Harr T, French LE (2010). “Toxic epidermal necrolysis and Stevens-Johnson syndrome”. Orphanet J Rare Dis. 5: 39. doi:10.1186/1750-1172-5-39. PMCΒ 3018455. PMIDΒ 21162721.
- β Harr T, French LE (2010). “Toxic epidermal necrolysis and Stevens-Johnson syndrome”. Orphanet J Rare Dis. 5: 39. doi:10.1186/1750-1172-5-39. PMCΒ 3018455. PMIDΒ 21162721.
- β Chang YS, Huang FC, Tseng SH, Hsu CK, Ho CL, Sheu HM (2007). “Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis: acute ocular manifestations, causes, and management”. Cornea. 26 (2): 123β9. doi:10.1097/ICO.0b013e31802eb264. PMIDΒ 17251797.
- β Harr T, French LE (2010). “Toxic epidermal necrolysis and Stevens-Johnson syndrome”. Orphanet J Rare Dis. 5: 39. doi:10.1186/1750-1172-5-39. PMCΒ 3018455. PMIDΒ 21162721.
- β Choudhary S, McLeod M, Torchia D, Romanelli P (2013). “Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome”. J Clin Aesthet Dermatol. 6 (6): 31β7. PMCΒ 3718748. PMIDΒ 23882307.
- β Eshki M, Allanore L, Musette P, Milpied B, Grange A, Guillaume JC, Chosidow O, Guillot I, Paradis V, Joly P, Crickx B, Ranger-Rogez S, Descamps V (2009). “Twelve-year analysis of severe cases of drug reaction with eosinophilia and systemic symptoms: a cause of unpredictable multiorgan failure”. Arch Dermatol. 145 (1): 67β72. doi:10.1001/archderm.145.1.67. PMIDΒ 19153346.
- β PeyriΓ¨re H, Dereure O, Breton H, Demoly P, Cociglio M, Blayac JP, Hillaire-Buys D (2006). “Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist?”. Br. J. Dermatol. 155 (2): 422β8. doi:10.1111/j.1365-2133.2006.07284.x. PMIDΒ 16882184.
- β Eshki M, Allanore L, Musette P, Milpied B, Grange A, Guillaume JC, Chosidow O, Guillot I, Paradis V, Joly P, Crickx B, Ranger-Rogez S, Descamps V (2009). “Twelve-year analysis of severe cases of drug reaction with eosinophilia and systemic symptoms: a cause of unpredictable multiorgan failure”. Arch Dermatol. 145 (1): 67β72. doi:10.1001/archderm.145.1.67. PMIDΒ 19153346.
- β Wallace MR, Mascola JR, Oldfield EC (1991). “Red man syndrome: incidence, etiology, and prophylaxis”. J. Infect. Dis. 164 (6): 1180β5. PMIDΒ 1955716.
- β Sivagnanam S, Deleu D (2003). “Red man syndrome”. Crit Care. 7 (2): 119β20. PMCΒ 270616. PMIDΒ 12720556.
- β Renz CL, Laroche D, Thurn JD, Finn HA, Lynch JP, Thisted R, Moss J (1998). “Tryptase levels are not increased during vancomycin-induced anaphylactoid reactions”. Anesthesiology. 89 (3): 620β5. PMIDΒ 9743397.
- β Lin YJ, Cheng MC, Lo MH, Chien SJ (2015). “Early Differentiation of Kawasaki Disease Shock Syndrome and Toxic Shock Syndrome in a Pediatric Intensive Care Unit”. Pediatr. Infect. Dis. J. 34 (11): 1163β7. doi:10.1097/INF.0000000000000852. PMIDΒ 26222065.
Editor-In-Chief:
C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
