What is Toxic Shock Syndrome?

Toxic shock syndrome (TSS) is a rare, but life-threatening complication caused by certain bacterial infections, such as staphylococcus aureus (staph) bacteria, group A streptococcus (strep), or clostridium sordelli. With TSS, the bacterial infections release toxins into the bloodstream, and eventually into the organs. Although TSS can cause severe damage and be life-threatening, if it is caught early enough, it is curable with proper treatment.

TSS can happen in men, women, or children of all ages. Although TSS has been associated with women using superabsorbent tampons beyond the recommended 4-8 hours, fifty percent of TSS cases are not related to menstruation. In rare occasions, TSS can also occur after skin wounds, surgical incisions, burns, gynecological procedures, or nasal packing.

Signs and Symptoms

There are multiple signs and symptoms for TSS. Noticing any signs or symptoms of TSS early on is critical to reducing the risk of any life-threatening complications. Symptoms may include any of the following:

• High fever (with quick onset) or chills
• Vomiting or nausea
• Diarrhea
• Low blood pressure
• Red rash covering most of the body (similar to a sunburn or red dots on the skin)
• Shedding of the skin in large patches, specifically on the palms or soles of the feet (not as typical, but would usually appear 1-2 weeks after onset of other symptoms)
• Redness in the eyes, throat/mouth, and vagina (due to increased blood flow)
• Fatigue
• Malaise
• Headache
• Muscle aches
• Confusion
• Difficulty breathing
• Bruising due to low platelet count
• Low urine output, with sediment in the urine
• Shock
• Organ failure

Causes

The most common causes of toxic shock syndrome are bacterial infections from staphylococcus aureus, streptococcus pyogenes, and clostridium sordellii. Staphylococcus infections were first discovered in the late 1970’s early 1980’s and were associated with using super absorbent tampons. However, due to changes in how tampons are manufactured, the incidents of TSS from tampon use has significantly declined.

TSS related to streptococcus is more often seen in children and the elderly. People who have a weakened immune system, diabetes, heart disease, or chronic lung disease have an increased risk of TSS from streptococcus.

Toxic shock syndrome is associated with:

• Burns
• Surgical incisions
• Gynecological procedures
• Using contraceptive sponges, diaphragms, superabsorbent tampons, or menstrual cups
• Certain viral infections, such as chickenpox or influenza

Diagnosis

Your healthcare provider will make a diagnosis based on your symptoms and after an exam. Additionally, your doctor will order tests to determine the specifics of the infection. The tests may include:

• Blood cultures to find and identify microorganisms
• Urine test to check for bacteria
• Blood tests to check for liver and kidney functioning, measure blood clotting and bleeding times, cell counts, and electrolytes
• A complete blood count test (CBC), assessing for platelet levels
• Swabbing cells from the throat, cervix, and vagina
• Lumbar puncture (checking for bacteria in the spinal fluid)

Complications

Toxic shock syndrome can have a fast and sudden onset. Some of the most dangerous complications include:

• Shock
• Renal failure
• Death

Prevention

The risk of developing TSS can be minimized by taking appropriate precautions. The tampon industry no longer uses materials that were associated with higher rates of TSS. The Food and Drug Administration also requires manufacturers to label tampon boxes with specific instructions and guidelines that help prevent TSS.

Additional preventative measures include not keeping tampons in for more than 4-8 hours and trying to match the tampon’s absorbency measurement with how light or heavy your flow is. It is also helpful to alternate tampon use with sanitary napkins when your period flow is light. It is recommended to use the lowest absorbency tampon that is possible with your flow. If you are a woman and have had TSS before, avoid using tampons during your menstrual periods. TSS is more likely to recur in women who have had it before.

Other preventative measures include:

• Being diligent about keeping surgical incision areas clean to avoid infection
• If you notice any redness, swelling, or heat around an incision site, call your doctor immediately
• Follow instructions when using vaginal contraceptives

Treatment

Typically, with TSS, hospitalization is required. While at the hospital, various forms of treatment will be administered, depending on the bacterial infection and the severity. Treatments include:

• Antibiotics will be administered intravenously while the source of the infection is found (once the bacteria is identified, the antibiotics will be specified for the bacteria type)
• IV fluids may be administered to treat dehydration
• Medication will be given to improve blood pressure if it is low
• Any tampon or contraceptive device will be removed
• Infusions of intravenous immune globulins may be given in severe cases
• Surgically removing infected deep tissue
• Drain puss or blood from the wound to clear the infection