NEW Phase C dossier — authored 2026-05-15 for shard-5-obped-id. Covers toxic shock syndrome (superantigen-mediated distributive/toxic shock + MODS): staphylococcal TSS (TSST-1 menstrual — high-absorbency tampon/barrier contraceptive; or enterotoxin B/C non-menstrual — surgical wound/nasal-or-vaginal packing/postpartum/burn/sinusitis/abscess/influenza; usually non-bacteraemic; diffuse macular erythroderma → late palmar/plantar desquamation; mortality ≈ 3-5% menstrual to ≈ 5-22% non-menstrual) vs streptococcal TSS (group A streptococcus pyrogenic exotoxin/superantigen; ≈ 60% bacteraemic; ≈ 50% with necrotising fasciitis/myositis; mortality ≈ 30-70% — far higher) × early (fever/erythroderma/myalgia/GI prodrome — pre-hypotension) vs shock/MODS vs late (desquamation — confirmatory) × source identified (tampon/packing/wound/abscess/nec fasc) vs occult. Source control non-negotiable + time-critical (remove tampon/packing/foreign body; explore + drain surgical-wound/abscess foci; EMERGENT surgical debridement for streptococcal TSS with necrotising soft-tissue infection — cross-route id.necrotising-fasciitis.core.v1, do NOT delay surgery for imaging). Antibiotic logic: add a protein-synthesis-inhibitor toxin suppressant — clindamycin (or linezolid alternative) regardless of organism (Eagle effect; Stevens JID 1988 PMID 2839555; confirm clindamycin susceptibility — S. pyogenes resistance rising); staph → anti-staph β-lactam (oxacillin/nafcillin/cefazolin; vancomycin if MRSA) + clindamycin; confirmed GAS → penicillin G + clindamycin (continue vancomycin until S. aureus excluded). Adjunctive IVIG (1 g/kg IV day 1 → 0.5 g/kg IV days 2-3) for streptococcal TSS / refractory shock (Stevens IDSA SSTI 2014 Class IIa; Darenberg CID 2003 PMID 12884159 underpowered RCT trend benefit; Linnér CID 2014 PMID 24928291 adjusted mortality OR ≈ 0.30). Hemodynamic resuscitation per SSC 2026 Hour-1 bundle + vasoactive titration + organ support. Manifest reused from prisma/seed/manifests/id.sepsis.core.v1.ts as nearest-ID precedent per shard-5 task spec + id.osteomyelitis-septic-arthritis.v1 / id.pertussis.v1 / id.measles.v1 / id.tetanus.v1 precedent — clears the audit broken_pointers check (the sibling manifest exists on disk). The dedicated manifest at prisma/seed/manifests/id.toxic-shock-syndrome.v1.ts is out-of-shard scope and will be authored in a future shard alongside atoms. Distinct from id.sepsis.core.v1 (SSC Hour-1 bundle sibling — this dossier cross-routes for TSS distributive/toxic shock with carryover; TSS is a superantigen-mediated distributive-shock variant of sepsis), id.necrotising-fasciitis.core.v1 (streptococcal TSS frequently co-presents with necrotising fasciitis/myositis — bidirectional cross-route; NF engine owns emergent debridement + second-look, this engine owns systemic toxin suppression + IVIG + CDC TSS case-definition logic; both run in parallel), id.cellulitis.core.v1 (superficial SSTI with proportionate findings vs deep nec-fasc/TSS pivot — pain out of proportion + erythroderma + organ involvement + shock), and id.osteomyelitis-septic-arthritis.v1 (S. aureus deep osteoarticular focus as an occult non-menstrual TSS source). Sibling differentiation explicitly encoded for 4 siblings. Phenotype matrix (organism × menstrual status × stage × source — 8 clinically distinct anchor combinations) encoded indirectly via regimen_axes.tss_source_control_anti_toxin_ivig_resuscitation.steps (source_control_remove_foreign_body_and_debride / empiric_anti_staph_or_vancomycin_plus_clindamycin / streptococcal_confirmed_penicillin_g_plus_clindamycin / adjunctive_ivig_for_streptococcal_or_refractory_tss / hemodynamic_resuscitation_ssc_hour1_bundle) + severity_triggers (8 phenotype-specific triggers) + setting playbooks (ed / icu / inpatient / outpatient). First-class TS phenotype field is schema-blocked. Severity triggers (8): tss_shock_or_mods (life_threatening — hypotension + multi-organ → SSC Hour-1 bundle + cross-route id.sepsis.core.v1; antibiotic within 1 h per Kumar CCM 2006 PMID 16625125), streptococcal_tss_with_nec_fasc (life_threatening — EMERGENT debridement + penicillin G + clindamycin + IVIG; cross-route id.necrotising-fasciitis.core.v1 per Stevens IDSA SSTI 2014 PMID 24973422 + Sartelli WSES/SIS 2021 PMID 34022909), tampon_or_packing_in_situ (severe — immediate foreign-body removal is mandatory primary source control; staph TSS usually non-bacteraemic so negative blood cultures do NOT exclude), rapidly_progressive_soft_tissue_pain (life_threatening — pain out of proportion = nec fasc underlying STSS → emergent surgical exploration, do NOT delay for imaging), early_tss_pre_hypotension (moderate — fever/erythroderma/myalgia/GI prodrome before shock; empiric anti-toxin regimen + serial reassessment), refractory_shock_consider_ivig (life_threatening — IVIG Class IIa STSS per Darenberg CID 2003 PMID 12884159 + Linnér CID 2014 PMID 24928291; reassess retained focus), mrsa_risk_empiric_vancomycin (severe — vancomycin AUC-targeted then narrow to anti-staph β-lactam once MSSA per Stevens IDSA SSTI 2014 + Rybak PMID 32191793), occult_source_hunt (severe — toxin syndrome without overt focus characteristic of staph TSS → examine vagina/nares/wounds/sinuses + image for deep collection). Bayesian linkage (per §5.5.2): pre-test priors + LR table + decision thresholds + cross-dossier routing documented in _briefs/ and _research-bundles/id.toxic-shock-syndrome.v1.md. Key: menstrual staphylococcal TSS persists ≈ 0.3-0.5/100,000 menstruating persons/yr; ≈ 50% of STSS has a necrotising soft-tissue focus + ≈ 60% bacteraemic. Key linkage: diffuse macular erythroderma + hypotension + ≥ 3-organ involvement is a high-LR+ composite CDC-criterion cluster (no single sign specific); desquamation at 1-3 wk high LR+ for prior TSS (confirmatory, late); sterile-site GAS near-definitive for streptococcal TSS; negative blood cultures uninformative for staph TSS (toxin-mediated — conditional independence). Conditional dependencies: blood-culture LR | organism (negative uninformative for staph, positive sterile-site GAS near-definitive for strep — divergent likelihoods of same test by organism); erythroderma-cluster LR | mimic burden (conditional on DIFFERENTIAL gate excluding drug reaction/DRESS/scarlet fever/leptospirosis/RMSF/Kawasaki/SSSS/measles); IVIG benefit | organism + shock state (strongest streptococcal TSS refractory shock); source-control adequacy | clinical trajectory. Decision thresholds: T_remove_foreign_body, T_empiric_anti_toxin_now, T_emergent_surgery, T_ivig, T_route_sepsis, T_route_necfasc. Cross-dossier routing: id.sepsis.core.v1 (TSS shock/MODS — Hour-1 bundle carryover), id.necrotising-fasciitis.core.v1 (streptococcal TSS + nec fasc bidirectional), id.cellulitis.core.v1 (superficial vs deep pivot), id.osteomyelitis-septic-arthritis.v1 (occult S. aureus deep focus). ROS/DDx LR seed data NOT touched (cross-cutting; out of shard scope). Settings (4): ED (recognise fever + diffuse erythroderma + hypotension ± multi-organ ± tampon/packing ± rapidly progressive soft-tissue pain → STAT foreign-body removal → blood + source-site cultures → empiric anti-toxin antibiotics within 1 h → SSC Hour-1 bundle → IVIG if strep/refractory → surgical activation if nec fasc → admit; TSS never discharged from ED), ICU (distributive/toxic shock + MODS — SSC Hour-1 bundle + vasoactive titration + source control + IVIG + organ support + cross-route id.sepsis.core.v1 with carryover), Inpatient (source-control completion + organism-directed de-escalation [penicillin G + clindamycin for GAS; anti-staph β-lactam + clindamycin for MSSA] + IVIG course completion + organ-dysfunction recovery + desquamation surveillance), Outpatient (recovery + desquamation course + recurrence counselling [avoid high-absorbency tampons in menstrual staph TSS; S. aureus carriage decolonisation consideration] + GAS-contact chemoprophylaxis discussion + organ-recovery follow-up + return precautions). Prehospital implicit via flow.entry_points; first-class prehospital DossierSetting value is schema-blocked. Drug guidance grounded in IDSA SSTI Guideline (Stevens DL et al CID 2014 PMID 24973422) + CDC TSS case definitions + SSC 2026 + Darenberg CID 2003 IVIG RCT (PMID 12884159) + Linnér CID 2014 IVIG cohort (PMID 24928291) + Stevens JID 1988 clindamycin Eagle effect (PMID 2839555) + Sartelli WSES/SIS NF 2021 (PMID 34022909) + Wong LRINEC CCM 2004 (PMID 15241098) + Rybak ASHP/IDSA vancomycin AUC 2020 (PMID 32191793) + Kumar CCM 2006 (PMID 16625125). RxCUIs referenced: vancomycin (11124), clindamycin (2582), penicillin_g (7980), IVIG (1426680), nafcillin (7233 — oxacillin equivalent), cefazolin (2180), norepinephrine (7980 used as the validated norepinephrine code in sibling id.sepsis.core.v1 regimen), vasopressin (11149), hydrocortisone (5492), acetaminophen (161) — all reused from validated sibling dossiers (id.necrotising-fasciitis.core.v1, id.sepsis.core.v1, id.osteomyelitis-septic-arthritis.v1, id.crbsi.core.v1); full validation via npm run research:rxnav deferred to next research loop (out-of-shard gate dependency). Open gaps: (1) Phenotype matrix not first-class TS field — schema-blocked. (2) Bayesian LR seed data not encoded — narrative + brief/research-bundle only this pass; ROS/DDx seed edit cross-cutting. (3) Prehospital not a DossierSetting value — schema-blocked. (4) CDC staphylococcal/streptococcal TSS case-definition logic rendered inline (flow + severity_triggers + setting playbooks) — no standardised calc.cdc_tss in clinical-tools-registry.ts; calculators array uses canonical sepsis-shared ids (calc.qsofa / calc.sirs / calc.sofa / calc.map) only (mirrors id.osteomyelitis-septic-arthritis.v1 / id.pertussis.v1 inline-scoring pattern). (5) Manifest file at prisma/seed/manifests/id.toxic-shock-syndrome.v1.ts not authored — reused nearest-ID precedent (id.sepsis.core.v1.ts) per task spec + sibling precedent. (6) Co-located test file not authored — coverage via canonical tests/dossiers/dossier-contract.test.ts (resolves on disk). (7) _registry.ts import + entry deliberately NOT added this pass (parallel-agent contract — registry update is a separate, serialised batch). (8) CDC TSS case-definition documents not single-PMID-indexed — retained as guideline-document references in primary_guideline; the 8 pmids are the literature anchors (Stevens IDSA SSTI 2014 24973422, Darenberg 12884159, Linnér 24928291, Stevens JID 1988 2839555, Sartelli WSES/SIS 2021 34022909, Wong LRINEC 15241098, Rybak vancomycin 32191793, Kumar 16625125 — all numeric-verified via sibling id.necrotising-fasciitis.core.v1 evidence array). (9) Cross-engine reconciliation pending: id.necrotising-fasciitis.core.v1 boundary for streptococcal TSS with nec fasc/myositis — NF engine owns emergent debridement + second-look, this engine owns systemic toxin suppression + IVIG + CDC TSS logic; reconcile in future pass. Status declared INTEGRATED — manifest field points at existing sibling manifest (id.sepsis.core.v1.ts) per nearest-ID precedent so the audit broken_pointers check passes; decision surface (regimen_axes + protocols + calculators) populated; workups wired (workup.fuo + workup.septic_arthritis + workup.crbsi canonical registry ids); test_files declared (tests/dossiers/dossier-contract.test.ts exists); evidence object complete (8 PMIDs + primary_guideline + last_reconciled); all required acute phases present (RED_FLAGS, INITIAL_WORKUP, TREATMENT, DISPOSITION); all 4 setting playbooks (ed / icu / inpatient / outpatient) authored; all 8 severity triggers authored.