Clinical Spectrum of Nonmenstrual Toxic Shock Syndrome (TSS): Comparison with Menstrual TSS by Multivariate Discriminant Analyses

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Abstract
To further characterize the clinical spectrum of nonmenstrual toxic shock syndrome (NMTSS), we contrasted and compared the clinical and laboratory features of 24 patients with NMTSS with those of 21 patients with menstrual TSS (MTSS), using univariate and stepwise discriminant analyses. In contrast to patients with MTSS, those with NMTSS comprised a heterogeneous group with varying host factors and clinical presentations. The NMTSS group differed from the MTSS group in terms of the frequency of prior antimicrobial treatment (46% vs. 16%;P = .05), the rate of nosocomial acquisition (65% vs. 0;P = .0001), and the time of onset of fever and rash in relation to the initial symptoms (P = .005 and .03, respectively, with earlier onset in the NMTSS group). In addition, NMTSS patients experienced more frequent renal and eNS complications and less frequent musculoskeletal involvement (P = .07 in all three cases). Stepwise discriminant analysis identified four variables (delayed onset of TSS symptoms after precipitating injury or event, more frequent eNS manifestations, less frequent musculoskeletal involvement, and higher degree of anemia) differentiating NMTSS patients from MTSS patients (P < .05). Isolates of Staphylococcus aureus associated with NMTSS and MTSS produced TSS toxin 1 (TSST-1) with comparable frequency (62% vs. 84%; P = .2), but production of staphylococcal enterotoxin A (SEA) was less common in NMTSS than in MTSS (33% vs. 74%; P = .01). Furthermore, MTSS-associated isolates more commonly coexpressed TSST-1 and SEA than did NMTSS-associated isolates (68% vs. 28%; P = .01). Overall mortality was not significantly different in the two groups (NMTSS, 12.5%; MTSS, 4.8%). Recurrence was more frequent for both NMTSS and MTSS in the absence of specific antistaphylococcal therapy (P < .05). We conclude that NMTSS is clinically and microbiologically distinct from MTSS. Early recognition and treatment are essential to reduce both acute morbidity from and recurrence of this potentially life-threatening illness.

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