Table 2.

The differential presentations of influenza, COVID-19, Toxic Shock and Streptococcal Toxic Shock syndromes

Toxic Shock Syndrome (TSS) (S. aureus)	Streptococcal Toxic Shock Syndrome (STSS) due to GAS	Influenza	COVID-19	Enterovirus
Often associated with only a small ‘insignificant’ wound infection Rarely now related to menstruation	May be of vaginal origin Often contact history of GAS (sore throat/impetigo/scarlet fever)	Seasonal; autumn-winter	Not known	Seasonal; Spring/summer
General malaise, myalgia	Rapid illness and prostration, myalgia	Very acute onset, severe myalgia Headache, prostration	‘Influenza like illness’	Fatigue, myalgia and may have gastrointestinal symptoms
Usually no cough or sore throat	Usually no cough Recent sore throat common	Cough, sore throat upper respiratory tract symptoms, runny nose	Cough Shortness of breath with pneumonia later Sore throat uncommon	Cough, [pneumonia uncommon]
Headache	Headache	Headache	Headache not common	Severe headache and viral meningitis common
High temp/low temp, confusion, prostration	High temp/low temp, confusion, prostration	Fever, severe prostration	Fever, weakness	Fever
Vomiting; due to exotoxin production (acting as enterotoxins)	Exotoxins causing diarrhoea and vomiting	Diarrhoea (especially H1N1 ‘swine flu’) Viral gut replication	Diarrhoea 5%–10%	May or may not have diarrhoea
No loss of taste/smell	No loss of taste/smell	No loss of taste/smell	Loss of taste/smell common	No loss of taste/smell
All cases of TSS (i.e. staphylococcal TSS) have confluent erythematous rash Multi-organ failure	Multi-organ failure 10% patients have a rash	No rash May have multi-organ failure late in illness	Rarely, chillblain like rash some days into the illness Multi-organ failure late in illness	Variable rash, usually maculopapular but may be vesicular and involve mouth
Haemoptysis not associated with TSS, (usually associated with PVL-S. aureus pneumonia)	Primary GAS pneumonia rare but haemoptysis a feature	Haemoptysis (if severe influenza pneumonia)	Haemoptysis rare
Very high or rapidly climbing CRP and creatine kinase, lymphopenia	Very high or rapidly climbing CRP and creatine kinase, lymphopenia	Low CRP (unless bacterial superinfection), lymphopenia	Low CRP (unless cytokine storm or bacterial superinfection) lymphopenia	Low CRP lymphopenia
Treat with anti- exotoxin antimicrobials and IVIG if not responding	Treatment with anti- exotoxin antimicrobials And IVIG if not responding	Oseltamivir	No known effective drug therapy	IVIG for neonate if becomes septic