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Toxic Shock Syndrome

(TSS)

Definition

Toxic shock syndrome (TSS) is a group of symptoms throughout the body. This illness can progress rapidly. It can lead to a failure of multiple body systems. Toxic shock syndrome can be fatal.
There are two types of TSS:
  • Menstrual type —associated with menstruation and tampon use
  • Nonmenstrual type—can occur in men, women and children

Causes

TSS is caused by toxins released from certain bacteria. Bacteria most often associated with TSS include:
  • Staphylococcus aureus
  • Streptococcus pyogenes
Bacteria infects the body through cuts or sores. The bacteria can create toxins as it grows. These toxins are harmful to many of your body's systems. The damage to your body is what causes the range of symptoms.
Immune System
Immune system white blood cell
The immune system creates antibodies to fight bacteria.
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TSS was originally associated with tampon use. It was most common in women who used a particular type of highly absorbent tampons. As a result, these tampons were removed from the market. The number of TSS infections due to tampons has since significantly decreased.

Risk Factors

Factors that increase your risk of TSS include:
  • Tampon use
  • Birth control devices placed in the vagina (eg, sponge, diaphragm, cervical cap)
  • Chickenpox
  • Skin lesions (eg, burns )
  • Wound packing—done after certain surgeries or procedures such as sinus or nasal surgery
  • Surgical wounds
  • Recent childbirth
  • Alcohol abuse
  • HIV infection

Symptoms

A person with TSS often appears very ill. Symptoms usually come on suddenly. Fever, chills, and body aches may start up to four days before other symptoms develop such as:
  • Fever of 102ºF (39ºC) or greater
  • Sunburn-like rash
  • Lightheadedness, dizziness
  • Chills
  • Nausea
  • Vomiting
  • Diarrhea
  • Abdominal pain
  • Sore throat
  • Red eyes
  • Headache
  • Confusion
  • Agitation
  • Sleepiness
  • Joint or muscle pain
  • Vaginal discharge (may be watery or bloody)
  • Swelling in the face and eyelids
  • Skin peeling off, especially palms of hands and soles of feet (occurs late in disease, 1-2 weeks after initial illness)
The initial symptoms may improve, as the disease progresses. Symptoms of severe TSS include:
  • Fainting, severe lightheadedness and dizziness (due to very low blood pressure)
  • Difficulty breathing
  • Seizures
  • Fluid retention
The infection can lead to severe complications such as:
  • Kidney failure—little or no urine production
  • Gangrene
  • Pancreatitis
  • Heart problems
  • Liver failure
  • Low platelet count

Diagnosis

The doctor will do a physical and pelvic exam. The diagnosis is most often based on the fever, the rash, low blood pressure, and problems affecting multiple body systems.
Tissue from the suspected wound will be tested for bacteria. However, these tests may be negative even if you have TSS.
Other blood and urine tests may be done to rule out other medical conditions.

Treatment

Treatment aims to support your life and reverse the process of organ deterioration. You may need to be monitored in the intensive care unit.
Treatment includes:

Cleaning and Draining the Infection Site

The wound will be reopened. Water will be poured over the wound to clean the area. Any packing from a previous procedure will be removed.
If a birth control device is in the vagina, the doctor takes it out. If the TSS is menstrual type, the vagina may be flushed out with saline.

Supportive Care

To support your body while you heal:
  • IV fluids will be given to replace lost fluids.
  • Your breathing may need to be supported by a machine. It may be needed if your lungs are affected or you are too fatigued to breathe well on your own.
  • Dialysis may be needed with kidney failure. Dialysis takes over the job of the kidneys.
  • Medication may be given to:
    • Raise blood pressure
    • Lower fever
  • Antibiotics may be given. They do not cure TSS but can help to manage the condition.
  • IV immunoglobulin may be given to support the immune system.

Prevention

You can decrease your risk of menstrual associated TSS with the following steps:
  • Do not use tampons continuously when menstruating.
  • Alternate using a tampon with a sanitary pad.
  • Switch to sanitary pads at night.
  • Do not use super absorbency tampons.
  • Change tampons frequently during the day.
  • Store tampons in a clean, dry place.
  • Wash your hands with soap and water before and after you put in or take out a tampon.
  • Use a lower absorbency tampon if you find the tampon is irritating or hard to pull out.
  • Use tampons only during menstruation.
  • Seek medical care for infected wounds.
  • If you have had TSS, do not use tampons or place birth control devices in your vagina.
Most other forms of the disease are not currently preventable.

RESOURCES

American Congress of Obstetricians and Gynecologists http://www.acog.org/

Centers for Disease Control and Prevention http://www.cdc.gov/

CANADIAN RESOURCES

The Society of Obstetricians and Gynaecologists of Canada http://www.sogc.org/

Women's Health Matters http://www.womenshealthmatters.ca/

References

Imöhl M, van der Linden M, Reinert RR, Ritter K. Invasive group A streptococcal disease and association with varicella in Germany, 1996-2009. FEMS Immunol Med Microbiol . 2011 Jun;62(1):101-109.

Kasper DL, Harrison TR. Harrison's Principles of Internal Medicine . 16th ed. New York, NY: McGraw-Hill; 2005.

Mandell G, Douglass RG, Bennett JE. Principles and Practice of Infectious Diseases . 5th ed. New York, NY: Churchill Livingstone, Inc; 2000.

Tampons and Asbestos, Dioxin and Toxic Shock Syndrome. United States Food and Drug Administration website. Available at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PatientAlerts/ucm070003.htm . Accessed November 13, 2012.

Toxic shock syndrome. Children's Hospital of Pittsburgh website. Available at: http://www.chp.edu/CHP/P02550 . Accessed November 13, 2012.

Toxic shock syndrome. Nemours KidsHealth website. Available at: http://kidshealth.org/parent/infections/bacterial%5Fviral/toxic%5Fshock.html . Updated May 21, 2009. Accessed November 13, 2012.

Tyner HL, Schlievert PM, Baddour LM. Beta-hemolytic streptococcal erythroderma syndrome: a clinical and pathogenic analysis. Am J Med Sci . 2011 Aug 11.

Revision Information

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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