Chapter 13 : Intravenous Immunoglobulin Therapy in Superantigen-Mediated Toxic Shock Syndrome

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Toxic shock syndrome (TSS) is a serious acute bacterial disease characterized by fever, diffuse erythematous rash, hypotension, multiorgan involvement, and desquamation of the skin one to two weeks after onset. Various immunomodulatory agents and antisuperantigen therapeutic strategies have been proposed. One such strategy includes the administration of intravenous polyspecific immunoglobulin (IVIG). This chapter reviews the mechanistic actions and use of IVIG as adjunctive therapy for TSS. Patients were considered to have streptococcal TSS if they had hypotension in combination with two or more of the following: acute renal failure, coagulation abnormalities, liver abnormalities, adult respiratory distress syndrome (ARDS), generalized rash, and necrotizing fasciitis. The observation that staphylococcal TSS patients normally do not have detectable bacteremia, yet the patients demonstrate significant systemic features, suggested that TSS was the result of a toxemia. Most strains express several different superantigens, and strains harbor in general genes encoding three to five of the superantigens, but the repertoire of genes varies between strains. and are major human pathogens largely due to their ability to modulate and exploit the host defense mechanisms. Conventional therapy of invasive infections has consisted of antimicrobials and, when necessary in severe invasive disease, support of vital functions for those patients with streptococcal TSS and surgery for those patients with necrotizing fasciitis.

Citation: Norrby-Teglund A, Low D, Kotb M. 2007. Intravenous Immunoglobulin Therapy in Superantigen-Mediated Toxic Shock Syndrome, p 197-215. In Kotb M, Fraser J (ed), Superantigens. ASM Press, Washington, DC. doi: 10.1128/9781555815844.ch13
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Figure 1.

Proposed mechanisms of action of intravenous immunoglobulin in TSS caused by or Intravenous immunoglobulin interacts at different stages in the bacterial pathogenesis to improve bacterial clearance and to neutralize toxins, superantigens, and proteases, as well as to improve immunosuppression through various immunomulatory effects. MSCRAMM, microbial surface components recognizing adhesive matrix molecules; SAg, superantigens; SCP, streptococcal cysteine protease, i.e., SpeB; SLO, streptolysin O; EAP, extracellular adherence protein; PVL, Pan-ton-valentine leukocidin; APC, antigen-presenting cell; FcR, Fc receptor.

Citation: Norrby-Teglund A, Low D, Kotb M. 2007. Intravenous Immunoglobulin Therapy in Superantigen-Mediated Toxic Shock Syndrome, p 197-215. In Kotb M, Fraser J (ed), Superantigens. ASM Press, Washington, DC. doi: 10.1128/9781555815844.ch13
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Table 1.

Clinical and epidemiologic aspects of streptococcal and staphylococcal toxic shock syndrome (TSS)

Citation: Norrby-Teglund A, Low D, Kotb M. 2007. Intravenous Immunoglobulin Therapy in Superantigen-Mediated Toxic Shock Syndrome, p 197-215. In Kotb M, Fraser J (ed), Superantigens. ASM Press, Washington, DC. doi: 10.1128/9781555815844.ch13
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Table 2.

Virulence factors of and grouped according to function

Citation: Norrby-Teglund A, Low D, Kotb M. 2007. Intravenous Immunoglobulin Therapy in Superantigen-Mediated Toxic Shock Syndrome, p 197-215. In Kotb M, Fraser J (ed), Superantigens. ASM Press, Washington, DC. doi: 10.1128/9781555815844.ch13
Generic image for table
Table 3.

Intravenous polyspecific immunoglobulin (IVIG) as adjunctive therapy in streptococcal and staphylococcal TSS

Citation: Norrby-Teglund A, Low D, Kotb M. 2007. Intravenous Immunoglobulin Therapy in Superantigen-Mediated Toxic Shock Syndrome, p 197-215. In Kotb M, Fraser J (ed), Superantigens. ASM Press, Washington, DC. doi: 10.1128/9781555815844.ch13

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