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Induction of nitric oxide synthase activity by toxic shock syndrome toxin 1 in a macrophage-monocyte cell line.

Toxic shock syndrome toxin 1 (TSST-1) is a Mr 22,000 protein produced by Staphylococcus aureus. It is thought to be the cause of toxic shock syndrome. We investigated the hypothesis that TSST-1 induces nitric oxide (NO) synthase and that the NO formed may be involved in the pathogenesis of toxic shock syndrome. We used the murine monocyte-macrophage cell line J744.2 that responds to TSST-1 and also expresses NO synthase activity upon immunological stimulation. J774.2 macrophages stimulated with TSST-1 (10-100 nM) generated nitrite, a breakdown product of NO, and induced concentration-dependent elevations of cGMP in the pig kidney epithelial cell line (LLC-PK1). This latter effect was due to the generation of L-arginine-derived NO for it was (i) abolished by oxyhemoglobin (10 microM), a scavenger of NO, or by methylene blue (10 microM), an inhibitor of NO-activated guanylate cyclase; (ii) potentiated by superoxide dismutase (100 units/ml), which prolongs the life of NO; (iii) inhibited by NG-monomethyl-L-arginine (0.3 mM), an inhibitor of NO synthase; (iv) significantly decreased when L-arginine (0.4 mM) in the medium was replaced by D-arginine (0.4 mM). Moreover, TSST-1 (100 nM) enhanced the activity of cytosolic NO synthase in J774.2 cells. Hydrocortisone (1 microM) but not indomethacin (5 micrograms/ml) or salicylic acid (5 micrograms/ml) prevented the generation of NO2- and the increases in cGMP levels in LLC-PK1 cells induced by J774.2 cells stimulated with TSST-1. The effects of hydrocortisone were partially reversed by coincubation with RU 486 (1 microM), an antagonist of glucocorticoid receptors. Thus, TSST-1 and perhaps other exotoxins produced by Gram-positive bacteria induce NO synthase and the increased NO formation may contribute to toxic shock syndrome and possibly to changes in the immune responses that accompany infection.

Amino Acid Oxidoreductases↗

Toxic shock syndrome and other tampon related risks.

Most of the recent cases of toxic shock syndrome (TSS) reported have occurred in menstruating women and adolescents although some cases have been reported in nonmenstruating women, children, and men. The disease is characterized by sudden onset of high fever, vomiting, and diarrhea and can rapidly progress to hypotension and shock. Tampon use has been linked to development of toxic shock syndrome, and Staphylococcus aureus has been cultured from a significant number of cases. The exact roles played by both Staphylococcus aureus and tampons in the pathogenesis of toxic shock syndrome remains unknown. Tampons also have been associated with other health problems in women. Nurses can advise preventive measures to reduce the risks of developing toxic shock syndrome and other tampon-related problems.

Adolescent↗

Aseptic arthritis in a man with toxic shock syndrome.

Synovitis in toxic shock syndrome (TSS) is an unusual finding. A 31-year-old man presented with pain and swelling in both knees and was found to have TSS, secondary to a septic bursitis caused by Staphylococcus aureus. Immune complexes were not detected in serum or synovial fluid, and the S aureus was not recovered from the inflamed joints. Antibodies against the TSS toxin-1 were detected in serum and synovial fluid, but in lower levels than would be seen in a normal control serum. Complement studies implicated alternative pathway activation by a marked diminution in C3 levels compared with C4 levels, and by lower levels of factor B than would be found in other inflammatory joint diseases. The diagnostic dilemma posed by TSS in a man is discussed.

Adult↗

Therapeutic Approaches to Streptococcal Toxic Shock Syndrome.

The streptococcal toxic shock syndrome (STSS) is a severe, life-threatening condition characterized by hypotension and multiorgan system dysfunction associated with infection by the group A Streptococcus (GAS) or rarely by streptococci of other Lancefield serogroups. It is associated with a soft tissue infection, such as necrotizing fasciitis, in about half of the cases; the remainder are secondary to a variety of other invasive and noninvasive GAS infections. Although the pathophysiology of STSS is not yet fully understood, there are compelling reasons to believe that the syndrome results at least in part from the action of the streptococcal pyrogenic exotoxins, which act as superantigens. Patients with STSS should be admitted to an intensive care unit for support of cardiovascular, respiratory, and renal function as required. In experimental models of overwhelming GAS infection, clindamycin has greater efficacy than penicillin, and therapy with this agent is recommended. Penicillin, to which GAS are uniformly susceptible, may be used in addition to clindamycin. Limited clinical experience, most of which is anecdotal, suggests marked improvement in some STSS patients after administration of intravenous immunoglobulin. Even in the absence of conclusive data, the potential benefits of intravenous immunoglobulin in this highly lethal disease make its use reasonable in life-threatening cases. Other experimental approaches are also discussed, such as the use of anti-tumor necrosis factor monoclonal antibodies and plasmapheresis.

Journal Article↗

Toxic shock syndrome: a review.

Toxic shock syndrome (TSS) is an acute illness that affects multiple organ systems. It is a disorder of particular interest to obstetricians and gynecologists because it primarily affects otherwise healthy menstruating women who use tampons. The pathogenesis remains unknown. However, Staphylococcus aureus has been isolated from either focal lesions or the vagina in most cases and a staphylococcal exotoxin is believed to be the causative agent. The epidemiologic characteristics, risk factors, clinical findings, criteria for diagnosis, and recommendations for treatment are reviewed.

Diagnosis, Differential↗

Recombinant expression and neutralizing activity of an MHC class II binding epitope of toxic shock syndrome toxin-1.

Toxic shock syndrome (TSS) is caused by the staphylococcal superantigen, TSST-1. The MHC class II binding domain of TSST-1 containing a conserved sequence with other related staphylococcal enterotoxins, comprising TSST-1 residues 47-64 [(T(47-64)], was expressed as a fusion protein with either glutathione-S-transferase (GST(47-64)), filamentous phage coat protein (pIII(47-64)), or E. coli outer membrane porin protein (OprF(47-64)), or synthesized as a peptide conjugated to bovine serum albumin, BSA(47-64). GST(47-64), OprF(47-64) and BSA(47-64), but not pIII(47-64), all induced high-titer T(47-64)-specific antibodies in Balb/c mice. However, only anti-GST(47-64) antibodies inhibited (125)I-TSST-1 binding to MHC class II and abrogated TSST-1-induced T cell mitogenesis and TNFalpha secretion in human peripheral blood mononuclear cells. Purified GST(47-64) also inhibited (125)I-TSST-1 binding in a dose-dependent manner. These findings suggest that GST(47-64) may have potential as a recombinant peptide vaccine or TSST-1 receptor inhibitor against TSS.

Animals↗

Human peripheral gammadelta T cells potentiate the early proinflammatory cytokine response to staphylococcal toxic shock syndrome toxin-1.

Toxic shock syndrome toxin (TSST)-1 is a superantigen known to profoundly induce proinflammatory cytokines by activation of V beta -specific alpha beta T cells, but its effect on gamma delta T cells, which normally constitute 1%-5% of peripheral blood mononuclear cells (PBMCs), is unclear. Here, we demonstrate that TSST-1 induced significantly higher levels of interferon (IFN)- gamma, tumor necrosis factor (TNF)- alpha, and interleukin (IL)-2, and a lower level of IL-10 in human PBMCs when the gamma delta subpopulation has been primed by isopentylpyrophosphate, compared with that in control PBMCs. Furthermore, depletion of the gamma delta subpopulation completely abrogated this effect. Thus, peripheral gamma delta T cells markedly modulate both the proinflammatory and anti-inflammatory cytokine responses of TSST-1.

Bacterial Toxins↗

Purification and purity assessment of toxic shock syndrome toxin 1.

Toxic shock syndrome toxin 1 (TSST-1) was partially purified from culture supernatants by SP-Sephadex C-25 ion-exchange chromatography and subsequent Sephadex G-75 gel filtration. This protein had an apparent molecular weight of 24,000 and an isoelectric point of 7.0. The NH2-amino acid sequence for the first 40 residues agreed completely with that predicted from the known TSST-1 genome. Ouchterlony immunodiffusion with monospecific rabbit antisera demonstrated a single line of identity with reference TSST-1 as well as with three preparations obtained from other investigators. When the purity of the different TSST-1 preparations was examined by Coomassie blue or silver staining after SDS-PAGE, only the major band at molecular weight 24,000 was apparent. However, multiple additional bands were seen in all preparations when visualized either by double staining with Coomassie blue stain followed by silver stain or by immunoblot using pooled human serum. Further purification of our preparation by reverse-phase high-performance liquid chromatography eliminated some, but not all, extraneous antigens. A final purification step by preparative SDS-PAGE resulted in an eluted protein that yielded only the 24-kDa TSST-1 band and a 48-kDa dimer by immunoblot. This material was endotoxin free (sensitivity limit, 10 pg/mL) and retained biologic activity for induction of cachectin and production of interleukin 1 by human monocytes. These data emphasize the need for stringent methods of assessment of purity in TSST-1 preparations.

Amino Acid Sequence↗

Influence of focal growth conditions on the pathogenesis of toxic shock syndrome.

Patients with toxic shock syndrome (TSS) had sequestered focal sites colonized or infected with Staphylococcus aureus significantly more frequently than did patients with scalded skin syndrome. Growth conditions within the infected foci of four patients with TSS included nearly physiological levels of pH, pO2, pCO2, protein, calcium, and magnesium. Two strains of S. aureus had typical TSS phenotypes (production of TSS toxin-1 [TSST-1] and protease), which were optimally expressed in vitro under conditions similar to those documented in vivo (6% CO2, pH 7.0, aerobic, high levels of protein). Altering any one of these growth factors significantly decreased production of TSST-1. In protein-containing media, depletion of divalent cations had a less-profound effect on organism growth and TSST-1 production. The unique in vivo environment in patients with non-menstrual TSS is similar to conditions associated with tampon use during menstruation. Growth conditions may play an important role in the expression of S. aureus phenotype and the pathogenesis of TSS.

Bacterial Toxins↗

Localization of biologically important regions on toxic shock syndrome toxin 1.

Toxic shock syndrome toxin 1 (TSST-1) contains a long central alpha helix that forms the base of two grooves on opposite sides of the molecule. Previous studies indicated that residues 132, 135, and 140 along the back of the central alpha helix are important in the biological activities. We made mutations of additional central alpha-helix residues exposed along this groove on the back of TSST-1. The proteins were purified, shown not to have gross alteration in structure, and tested for both superantigenicity and ability to elicit lethal TSS, using the superantigenicity, likely to because of alteration in T-cell receptor binding. Mutants H135A, Q136A, and E132K/ Q136K lost the ability to induce lethal TSS. The mutant Q136A was most increasing because it was superantigenic, yet nonlethal.

Animals↗

Managing toxic shock syndrome with antibiotics.

Toxic shock syndrome (TSS) is a serious disorder with a worldwide prevalence of approximately 3/100,000 persons. TSS is mainly caused by Streptococcus pyogenes or Staphylococcus aureus. Thus, beta-lactam and lincosamides, such as clindamycin, are the first-line drugs. Yet, the mortality rate remains unacceptably high; highlighting the role of bacterial toxin-mediated activation of the inflammatory cascade in TSS pathogenesis. Further strategies should be targeted towards interfering with the interaction between bacterial toxins and host T cells. This paper aims to provide an overview of the epidemiology, pathomechanisms, and clinical presentation of TSS, and criteria for selecting drugs among available antibiotics.

Anti-Bacterial Agents↗

Immunobiologic and biochemical properties of mutants of toxic shock syndrome toxin-1.

Toxic shock syndrome (TSS) is a multisystem illness caused mainly by Staphylococcus aureus producing TSS toxin-1 (TSST-1). A variant of TSST-1 has been isolated from ovine mastitis S. aureus. This toxin, TSST-ovine (TSST-O) is only weakly T cell mitogenic, is nonpyrogenic, does not enhance endotoxin shock, and does not cause TSS in the miniosmotic pump model. The sequence of the ovine gene (tstO) differs from the TSST-1 gene (tstH) by 14 nucleotides that change seven amino acids in the mature protein of which two are in the C-terminal half. A gene fusion containing half of both tstH and tstO was made and cloned into S. aureus. The fusion protein contained the two C-terminal amino acid differences that are in TSST-O at residues 132 and 140. The fusion protein was not T cell mitogenic and did not elicit TSS in two rabbit models. Additional experiments used mutagenesis to change the lysine residue at position 132 of TSST-O to glutamate (TSST-OK132E), as exists in TSST-1, and to change the lysine residue of the human-ovine fusion at position 132 to glutamate (TSST-11140T). Both mutants were pyrogenic, enhanced endotoxin shock, and caused TSS in the miniosmotic pump model. However, the proteins were only partially T cell mitogenic. The restoration of lethality of TSST-O and the human-ovine fusion by changing the lysine to glutamate, as exists in TSST-1, indicates that residue 132 is important in lethality. The failure to regenerate complete T cell mitogenicity of the same mutants indicates that residues 132 and 140 are important for that activity.

Amino Acid Sequence↗

Postoperative toxic shock syndrome following adrenalectomy: a case report.

This report describes a fatal case of toxic shock syndrome following surgical procedure of adrenalectomy. Toxic shock syndrome is a severe multisystemic illness associated with Staphylococcus Aureus infection. The disease is usually associated with menstruation and tampon usage. However, it has recently been reported in the postoperative period following simple surgical procedures. The surgical wound does not usually appear infected. The syndrome is associated with specific strains of Staphylococci producing the toxic shock syndrome toxin 1 (TSST-1), that mainly contributes to the illness. The major clinical signs are: fever, diarrhea, cutaneous rash and hypotension. Toxic shock syndrome requires early recognition and prompt aggressive symptomatic treatment based essentially on fluids administration, appropriate intravenous antibiotics and corticosteroids.

Adrenalectomy↗

Production of gamma-hemolysin and lack of production of alpha-hemolysin by Staphylococcus aureus strains associated with toxic shock syndrome.

The hemolytic activity of toxic shock syndrome isolates of Staphylococcus aureus is enhanced when agarose is substituted for agar in blood plates or when strains are grown in liquid culture in the presence of 20% (vol/vol) CO2 in air. Hemolytic activity of a representative panel of toxic shock syndrome isolates was rigorously assessed both on blood agar and in liquid culture to unequivocally identify the predominant hemolysins produced. As determined by isoelectric focusing and Western immunoblotting, 15 of 15 TSS isolates produced gamma-lysin and 10 of 15 produced delta-lysin. None produced beta-lysin, and only 2 of 15 produced alpha-lysin. The low rate of alpha-lysin production was a most striking characteristic, since all strains were found to have the alpha-lysin gene by Southern blot hybridization.

Bacterial Proteins↗

Penetration of toxic shock syndrome toxin-1 across porcine vaginal mucosa ex vivo: permeability characteristics, toxin distribution, and tissue damage.

OBJECTIVE: The purpose of this study was to evaluate transvaginal penetration of toxic shock syndrome toxin-1 and its effects on permeability and tissue integrity in vitro with the use of excised porcine vaginal mucosa. STUDY DESIGN: Permeability to tritiated water (1 and 10 microg/mL applied toxin) and transmucosal flux of (35)S-methionine-labeled toxic shock syndrome toxin-1 (10 and 20 microg/mL) for up to 12 hours were assessed with the use of a continuous flow perfusion system. The location of labeled toxin that penetrated the mucosal tissue strata was determined. The integrity of toxin-treated, intact, scalpel-incised tissue was evaluated histopathologically. RESULTS: Toxic shock syndrome toxin-1 caused a non-dose-dependent increase in mucosal permeability and traversed the intact mucosa at a low rate without disrupting tissue integrity. In incised vaginal mucosa, toxic shock syndrome toxin-1 induced subepithelial separation and atrophy that were analogous to clinically relevant vaginal lesions that were reported in fatal cases of menstrual toxic shock syndrome. CONCLUSION: An in vitro model could be used to demonstrate that toxic shock syndrome toxin-1 permeates the vaginal mucosa and distributes throughout the tissue. Histologic evaluation of tissues that were exposed to toxic shock syndrome toxin-1 demonstrated lesions that were similar to those lesions that were reported in cases of menstrual toxic shock syndrome.

Animals↗

Toxic shock syndrome in the postoperative patient.

Toxic shock syndrome occurred in two patients within seven days of operation in women in whom Staphylococcus aureus was isolated from the wound incisions. Both patients had negative vaginal cultures. One patient was menstruating at the time of onset of the disease and the other was seven days' postpartum. Although toxic shock syndrome mainly occurs in menstruating women who use tampons and have positive vaginal cultures for Staphylococcus aureus, wound infection may also be a source for toxin production and adsorption.

Adult↗

[The toxic shock syndrome in male patients].

The toxic shock syndrome was observed in two young men (16 and 22 years). In one it occurred after a purulent scraping wound of the skin, in the other two days after an operation with seemingly normal wound conditions. All findings returned to normal in both patients after about five weeks. The syndrome of toxic shock can occur, regardless of age and sex, in Staphylococcus aureus infections of various kinds.

Adolescent↗

Toxic shock syndrome in three adolescent males.

Toxic shock syndrome (TSS) is associated with a spectrum of Staphylococcus aureus infections and is not just a disease of menstruating females. We report three cases of TSS in adolescent males. In one case the origin of infection was a cauterized wart that did not appear clinically infected. Two cases were associated with bacteremia and had demonstrable acute phase antibody to toxic shock syndrome toxin-1 (TSST-1). One of these patients died. The S. aureus strain from this patient did not produce TSST-1 but did produce enterotoxin D. The historical and clinical features of TSS are reviewed.

Adolescent↗