What is associated with Toxic Shock Syndrome, high Glomerular Filtration Rate (GFR) or high anaerobic metabolization?

Toxic Shock Syndrome is Associated with High Anaerobic Metabolization, Not High GFR

In Toxic Shock Syndrome (TSS), patients typically experience high anaerobic metabolization rather than high GFR.

Pathophysiology of Toxic Shock Syndrome

TSS is an acute, severe, toxin-mediated disease characterized by:

• Fever
• Hypotension
• Multiorgan system involvement 1
• Toxin production by Staphylococcus aureus or Streptococcus pyogenes 2

Renal Involvement in TSS

Rather than having high GFR, patients with TSS typically develop:

• Acute kidney injury (AKI) 1
• Decreased GFR due to:
  • Hypotension and shock state
  • Rhabdomyolysis (muscle breakdown) 3
  • Intrarenal vasoconstriction 4

Metabolic Changes in TSS

TSS is characterized by:

• High anaerobic metabolization due to tissue hypoperfusion
• Elevated lactate levels from anaerobic metabolism 1
• Systemic inflammatory response leading to metabolic acidosis

Evidence Supporting Anaerobic Metabolism in TSS

The evidence clearly shows that TSS patients develop:

1. Hypotension and shock state leading to tissue hypoperfusion 2
2. Elevated lactate levels, indicating anaerobic metabolism 1
3. Multi-organ dysfunction including acute kidney injury 1, 3

Why GFR is Decreased, Not Increased in TSS

In TSS, GFR typically decreases due to:

• Acute kidney injury from toxin-mediated damage
• Hypotension reducing renal perfusion
• Rhabdomyolysis causing tubular obstruction 3
• Intrarenal vasoconstriction from imbalance between endothelin and nitric oxide 4

According to kidney disease guidelines, acute kidney injury is defined as an abrupt decline in GFR resulting from ischemic or toxic injury to the kidney 4. This is consistent with the pathophysiology seen in TSS.

Clinical Implications

When managing a patient with TSS:

• Monitor for signs of AKI (decreased urine output, rising creatinine)
• Assess lactate levels to evaluate degree of anaerobic metabolism
• Provide aggressive fluid resuscitation to improve tissue perfusion
• Consider early vasopressor support if hypotension persists
• Administer appropriate antibiotics including those that suppress toxin production (e.g., clindamycin) 2

Common Pitfalls to Avoid

• Failing to recognize TSS early, which can lead to increased morbidity and mortality
• Not performing a pelvic examination in young females with unexplained shock 1
• Overlooking the possibility of rhabdomyolysis as a cause of renal dysfunction in TSS 3
• Delaying source control (e.g., removal of tampon or infected material)
• Underestimating fluid requirements in the resuscitation phase

In conclusion, TSS is associated with high anaerobic metabolism due to tissue hypoperfusion and shock, not high GFR. The correct answer is B. High anaerobic metabolization.