David Slotnick, M.D.
Toxic shock syndrome (TSS) is a very rare, life–threatening infection that is most often associated with the use of tampons and, in some cases, diaphragms and contraceptive sponges. However, it can also be triggered by other events (e.g., childbirth, surgery), injuries or certain illnesses.
While TSS most often occurs in menstruating women, it can also affect postmenopausal women, children and men.
TSS is caused by bacteria naturally present in the body in areas such as the nose, skin or vagina. These bacteria produce toxins that generally cause only mild infections, if any, in most people, such as strep throat or other strep infections or staph infections. This is because most people have developed immunity to these toxins at some point in their lives. However, in rare instances people who are not immune to the toxins can have a severe reaction to them. TSS may also rarely occur when the immune system is unable to combat the amount of toxins released during tampon use.
People at risk for TSS include:
- Women using tampons and/or barrier contraceptive devices (e.g., diaphragms). The risk increases if used during the first 12 weeks after childbirth.
- Those with an undeveloped or weakened immune system (e.g., children, cancer patients) who have undergone surgery, including those who have developed infections from deep wounds or other ruptures of the skin.
Symptoms of TSS develop suddenly and may include:
- High fever
- Vomiting and/or diarrhea
- A rash resembling a sunburn
- Muscle aches
- Redness of the eyes, mouth and/or throat
- Low blood pressure
If left untreated, TSS can put people at risk for organ failure, shock or death. Because the disease spreads rapidly and has life–threatening implications, treatment usually centers on taking care of the affected organs in addition to the use of antibiotics to kill the bacteria causing the infection. If the illness results from an infected wound, surgery may be required to rid the affected area of the bacteria. After the source of the infection is removed, a person’s condition often rapidly improves within a couple of weeks, provided there is no organ failure. Only 5 percent of all TSS cases in the United States are fatal, according to the U.S. Centers for Disease Control and Prevention (CDC).
About toxic shock syndrome
Toxic shock syndrome (TSS) is a rare but severe bacterial infection caused by either the Staphylococcus aureus (staph) or Streptococcus pyogenes (strep) bacteria. These bacteria are commonly found in the skin and mucous membranes such as those in the nose or vagina, and they produce toxins to which most people have developed immunity during their lives. However, people who have not developed immunity to these toxins can have a severe reaction to them, resulting in TSS.
TSS is potentially life–threatening because it can rapidly spread through the bloodstream to several different organs, including the lungs, kidneys and liver. Shock and failure of multiple organs can follow. Due to its rapid progression and severity, immediate hospitalization for monitoring and treatment is necessary. According to the U.S. Centers for Disease Control and Prevention (CDC), up to 5 percent of staph TSS cases in the United States are fatal. Strep TSS is also a severe infection, and about 50 percent of cases are fatal.
Many women associate TSS with the warning literature included in the packaging of tampons. The U.S. Food and Drug Administration (FDA) mandates that all manufacturers of these products give information about TSS and its association with high-absorbency tampons to consumers. For reasons not yet fully understood by scientists, TSS has been linked to prolonged tampon use during menstruation,and following childbirth.
However, TSS is more commonly triggered by complications from other events, illnesses and injuries. These include influenza,chickenpox, childbirth, surgery (such as a nasal or abdominal surgery), burns, deep skin cuts or wounds where there is a rupture of the skin present.
In addition, the syndrome has been linked to the use of certain birth control devices such as diaphragms or contraceptive sponges, which also include warning labels in their packaging.
TSS most commonly affects women of a childbearing age. However, because it is caused by toxin-producing bacteria that are naturally present in the body, it can occur in anyone.
Left untreated, the consequences of TSS are severe and can include:
- Kidney, heart and/or liver failure
- Profound shock (a life–threatening condition that occurs when the body is not getting enough blood flow)
Types and differences of toxic shock syndrome
There are two different types of toxic shock syndrome (TSS):
- Staph TSS. Caused by the Staphylococcus aureus bacteria, which produce one or more toxins in the body that trigger the illness. Staph TSS is linked to the use of tampons. However, the exact connection is not completely understood. Some researchers suspect that certain types of high-absorbency tampons provide a moist, warm home where the bacteria can thrive. Others have suggested that the superabsorbent fibers found in some tampons scratch the surface of the vagina, allowing a point for bacteria and toxins to enter the bloodstream. In the 1980s, a number of TSS cases were associated with the use of a certain brand of tampons. This product has since been removed from the marketplace, and the number of cases of tampon-related TSS has declined substantially.
Although staph TSS usually occurs in menstruating women, it can affect anyone who has any type of Staphylococcus infection, including pneumonia, abscess, skin or wound infection, septicemia(blood infection), or osteomyelitis(bone infection). It is considered a rare illness. However, there is a risk of recurrence.
- StrepTSS (STSS). Can occur following a Streptococcus pyogenes infection in the body, most often a skin infection or an infected wound. Streptococcal toxic shock syndrome (STSS) is a newly recognized disease that is related to the same strains of Streptococcus that have been nicknamed “flesh-eating” bacteria (necrotizing fasciitis). STSS is rare and most often appears after the strep bacteria have invaded areas of injured skin, such as cuts and scrapes, surgical wounds and even chickenpox blisters. It almost never follows a simple strep throat infection. Recurrence of strep TSS is rare.
Risk factors/causes of toxic shock syndrome
Toxic shock syndrome (TSS) is caused by toxin-producing bacteria that are naturally present in the body. It commonly affects women of a childbearing age, with between 1 and 2 women out of every 100,000 between the ages of 15 and 44 being affected, according to the U.S. Centers for Disease Control and Prevention (CDC). However, it can also occur in children, postmenopausal women and men. Risk factors for developing TSS include:
- Prolonged use of tampons, especially those with high absorbency. Risk increases with use during the first 12 weeks after childbirth.
- Use of barrier contraceptive devices (e.g., diaphragms, cervical caps, sponges). Use within 12 weeks of childbirth increases risk.
- Recent childbirth, especially in women who develop infections.
- Recent surgical procedures (e.g., nasal surgery, abdominal surgery), especially in people developing infections following such events.
- Weakened immune system. This may occur in young children, whose immune systems are not fully developed, and with bacterial or viral infections. But is it more commonly associated with people suffering from diseases that weaken the immune system, such as diabetes, cancer and HIV.
- Deep wounds, burns and/or other trauma that causes a break in the skin. This increases the risk of infection.
- Past TSS diagnosis. In some cases, especially in women, TSS can recur.
TSS occurs when the toxins produced by either the Staphylococcus aureus (staph) or Streptococcus pyogenes (strep) bacteria enter the bloodstream and cause a severe, rapidly progressing, harmful immune reaction adversely affecting the kidneys, heart and/or liver.
The staph and strep bacteria are present throughout the body in the nose, skin or vagina and are generally harmless. In most cases, the bacteria’s toxins only cause mild infections of the throat (e.g., strep throat) or skin (e.g., impetigo). Most people develop immunity to the toxins released by these bacteria at some point in their lives. The immune reaction involved in TSS only occurs in people who have not developed this immunity.
Children or those suffering from severe illness are less likely to have developed these antibodies.
People without the specific antibodies against strep or staph bacteria toxins can develop TSS at any time. However, certain events can trigger TSS. These events are different for TSS related to strep infections than for staph infections.
TSS caused by staph bacteria most often occurs after:
- Prolonged use of a tampon
- Prolonged use of barrier birth control devices (e.g., diaphragm or contraceptive sponge)
- Surgical procedures, such as nose surgery
- Using packing bandages
TSS caused by strep bacteria most often occurs after:
- Deep skin cuts or wounds where rupture of the skin is present
Signs and symptoms of toxic shock syndrome
The symptoms of toxic shock syndrome (TSS) vary and can progress quickly, becoming life–threatening within a couple of days if untreated. They typically appear two to three days following infection and may include:
- Severe flu–like symptoms (e.g., muscle aches and pains, stomach cramps, headache, sore throat, diarrhea).
- Sudden fever over 102 degrees Fahrenheit (38.9 degrees Celsius).
- Signs of shock (e.g., low blood pressure, rapid heartbeat, lightheadedness, fainting, nausea, vomiting, restlessness, confusion).
- A rash similar to sunburn, especially on the palms and soles of the feet. Usually after a week to two weeks, the skin on the areas affected by the rash begins to peel.
- Pain at the site of an infected wound or injury (if present).
- Redness in the nasal (nose) passages and inside the mouth and throat.
- Pink eye (bacterial conjunctivitis).
- Organ failure, especially of the heart, kidneys or liver
Diagnosis methods for toxic shock syndrome
Because it progresses so quickly and can be life threatening, toxic shock syndrome (TSS) is usually diagnosed and treated based on its symptoms without waiting for laboratory results. A complete medical history and physical examination are usually performed. The diagnosis of TSS is based on several criteria:
- Low blood pressure (hypotension)
- Rash that peels after one to two weeks
- At least three organs with signs of dysfunction
However, tests are administered to help identify the type of bacteria (Staphylococcus aureus or Streptococcus pyogenes) causing the infection. These may include:
- A routine complete blood count (CBC) of red and white blood cells as well as platelets.
- Cultures of blood and other body fluids and tissues (e.g., vaginal fluid, tissue from a wound or lesion). Cultures from the throat or a sputum sample, such as saliva, may also show the bacteria.
- Chest x-ray (to look for signs of damage to the lungs).
- Blood tests to rule out other infections with similar symptoms, such as:
- Sepsis (infection of the blood)
- Rocky Mountain spotted fever (tick-borne bacterial infection)
- Leptospirosis (bacterial infection caused by contact with the urine of infected animals)
- Typhoid fever (a life-threatening bacterial infection that is most common in developing countries)
- Sepsis (infection of the blood)
Treatment options for toxic shock syndrome
Toxic shock syndrome (TSS) progresses quickly and treatment is usually necessary before any test results are available. If signs of shock and/or organ failure are present, the patient will be admitted to a hospital’s intensive care unit (ICU). Such signs include low blood pressure, rapid heartbeat, lightheadedness, fainting, nausea, vomiting, restlessness, confusion and/or breathing problems (respiratory failure).
Treatment of TSS usually includes:
- Removal of the source of infection. If a woman is using a tampon, diaphragm or contraceptive sponge, it is promptly removed. Infected wounds are usually drained and cleaned to rid the area of bacteria. After the root of the problem is eliminated, a person typically shows rapid signs of improvement.
- Treatment of complications from the illness (e.g., low blood pressure, shock and organ failure). The type of treatment usually depends on what problems have developed. For example, if a person’s blood pressure begins to drop (hypotension), medication may be administered to stabilize it. If kidney failure is present, a TSS patient may need dialysis (a process by which a machine acts like an artificial kidney). In addition, large amounts of intravenous (IV) fluids are also administered to replace fluids lost from vomiting, diarrhea and fever and to avoid complications of low blood pressure and shock.
- Antibiotics. These kill the bacteria producing the toxins responsible for TSS. In addition to treating TSS, these may also help prevent recurrence. In some cases the bacteria may have developed antibiotic resistance, and the patient may require specific types of antibiotics and a longer treatment period.
- Intravenous immunoglobulin(IVIG). This involves administering fluid through an intravenous line that contains high levels of antibodies to help the body remove the specific toxins causing TSS. It is only used when TSS does not improve with antibiotics.
- Surgery to remove infected tissue. This is rarely needed, but is more common in cases where an infected wound was the trigger for TSS. It may be necessary if necrotizing fasciitis, a rare infection triggered by bacteria that destroy skin tissue, has set in. Because the tissues often die rapidly, it is also known as the “flesh-eating” bacteria.
If a TSS patient receives prompt treatment and no serious complications are present, complete recovery usually occurs within a couple of weeks.
Prevention methods for toxic shock syndrome
There are no specific guidelines to prevent toxic shock syndrome (TSS). Women are at greater risk in the first 12 weeks following childbirth. During this time, they can lower their risk by avoiding the use of tampons or barrier contraceptives (such as diaphragms, cervical caps or sponges) and intrauterine devices (IUD). Women who have contracted TSS in the past should altogether avoid the use of tampons, barrier contraceptives or even IUDs to avoid recurrence.
Women who choose to use tampons, diaphragms and other barrier contraceptives are encouraged to do so properly, including:
- Following package instructions when inserting tampons, diaphragms or contraceptive sponges.
- Washing hands with soap before inserting or removing these items from vagina.
- Changing tampons every four to eight hours or only using them for part of the day.
- Not leaving diaphragms or contraceptive sponges inside the vagina for more than 18 to 24 hours.
- Alternating the use of tampons with sanitary pads. For example, using pads at night and tampons during the day.
- Using tampons with the lowest absorbency needed. TSS risk is higher with super-absorbent tampons.
- Using care when inserting tampons or contraceptive devices (diaphragms and sponges) to minimize irritation in the vagina. If vaginal dryness is an issue, a lubricant may be used to help insert the tampon or contraceptive device.
- Avoiding the use of tampons or contraceptive devices if there is a skin infection near the vagina.
Additionally, everyone can reduce the risk of contracting TSS by caring for skin wounds or lesions to help prevent infection. This includes:
- Keeping all skin wounds or lesions clean (e.g., cuts, punctures, scrapes, burns, sores from shingles, insect or animal bites and surgical wounds) and changing bandages regularly. In addition to preventing infection, this also promotes healing.
- Keeping children from scratching chickenpox sores or any other open wounds and lesions.
- Reporting signs of infection of a physician. These may include redness, swelling, tenderness or associated fever.
Questions for your doctor regarding TSS
Preparing questions in advance can help patients have more meaningful discussions with healthcare professionals regarding their conditions. Patients may wish to ask their doctor the following questions related to toxic shock syndrome (TSS):
- How can I help prevent TSS?
- How will I know if my symptoms are related to TSS?
- What is the likely course of TSS?
- Will the regular use of tampons put me at risk for TSS?
- How will you diagnose TSS?
- Will I require hospitalization for my TSS?
- What are the treatment options for TSS and how effective are they?
- What is the long–term outlook for TSS with and without treatment?
- Can I use tampons again after having TSS?
- What are the odds that my TSS may recur?