Toxic Shock Syndrome (TSS)

What Is Toxic Shock Syndrome (TSS)? What Causes Toxic Shock Syndrome?
Toxic shock syndrome, also known as TSS, is a serious condition which mainly affects menstruating women using tampons. The patient develops a high fever, diarrhea, vomiting and muscle ache. This is followed by hypotension (low blood pressure), which may eventually lead to shock and death. In some cases there may be a sunburn-like rash with skin peeling.

Experts are not sure why such a significant proportion of toxic shock syndrome patients are women who are menstruating and using a tampon - especially "super absorbent" tampons.

Toxic shock syndrome may also occur as a result of an injury, burn or as a complication of localized infections, such as a boil, as well as with the use of contraceptive sponges.

In a large majority of cases toxic shock syndrome occurs as a result of toxins produced by Staphylococcus aureus (staph) bacteria. In may also result from toxins produced by group A Streptococcus (strep) bacteria. Streptococcal toxic shock syndrome is sometimes referred to as toxic shock-like syndrome (TSLS) or Streptococcal Toxic Shock Syndrome (STSS).

According to the National Health Service (NHS), UK, approximately 20 patients develop toxic shock syndrome each year in the United Kingdom, of which about 3 die. According to the Centers for Disease Control and Prevention (CDC), USA, toxic shock syndrome affects approximately 1 to 2 in every 100,000 women aged 15-44 years in the USA every year.

According to Medilexicon's medical dictionary:
    Toxic shock syndrome (TSS) is " infection with toxin-producing staphylococci, occurring most often in the vagina of menstruating women using superabsorbent tampons but also prevalent in many soft tissue infections and characterized by high fever, vomiting, diarrhea, a scarlatiniform rash followed by desquamation, and decreasing blood pressure and shock, which can result in death; hyperemia of the conjunctival, oropharyngeal, and vaginal mucous membranes also occurs."

What are the signs and symptoms of toxic shock syndrome?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

Signs and symptoms of TSS (toxic shock syndrome) develop suddenly:
  • Sudden high fever (first symptom)
  • The following signs and symptoms normally appear within a few hours:
  • Vomiting
  • Diarrhea
  • Sunburn-like skin rash, particularly in the palms and soles
  • Redness of eyes, mouth and throat
  • Fainting
  • Feeling faint
  • Muscle aches
  • Dizziness
  • Confusion
  • Hypotension (low blood pressure)
  • Seizures
  • Headaches
When to see a doctor
If you experience the signs and symptoms described above, especially if you are menstruating or have just finished menstruating and have been using tampons, or if you have a skin or wound infection, call your doctor immediately. Explain to your doctor what your symptoms are and how long you have had them for. If you are wearing a tampon remove it immediately. Tell your doctor:
  • If you have been wearing a tampon
  • If you have recently suffered a burn or skin injury
  • If you have a boil, or a blister that has become infected

What are the causes of toxic shock syndrome?

Scientists have been investigating the causes of TSS for over two decades and are still baffled. 20% to 30% of all humans carry the TSS causing bacterium, Staphylococcus aureus on their skin and nose; usually without any complications. Most of us have antibodies which protect us. Scientists believe that some of us do not develop the necessary antibodies.

Some experts suggest that the super-absorbent tampons - the ones that stay inside the body the longest - become breeding grounds for bacteria, while others believe the tampon fibers may scratch the vagina, making it possible for bacteria to get through and into the bloodstream. However, both are just theories without any compelling evidence to back them up.

We do know that the bacteria get into the body via wounds, localized infections, the vagina, the throat or burns. When the toxins (produced by the bacteria) enter the bloodstream they mess up the blood pressure regulating process, resulting in a hypotension (low blood pressure). Hypotension can cause dizziness and confusion (shock). The toxins also attack tissues, including organs and muscles. Kidney failure is a common TSS complication.

TSS does not only develop in young menstruating women. Older women, men and children may also be affected. Women who have been using a diaphragm or a contraceptive sponge have a slightly higher risk of developing TSS. In fact, anyone with a staph or strep infection has the potential to develop TSS (even though it is extremely rare).

How is toxic shock syndrome diagnosed?

To date, there is no specific TSS test. The doctor needs to identify the most common symptoms, as well as checking for signs of organ failure.

Blood and urine tests - these help determine organ function (or organ failure).

According to the National Health Service (NHS), UK, a confident TSS diagnosis can generally be made when:
  • The patient's temperature is above 38.9C (102.02F)
  • The patient's systolic blood pressure is below 90 mmHG
  • The patient has a skin rash
  • There is evidence that at least three organs have been affected by the infection

What are the treatment options for toxic shock syndrome?

The medical team's aim is to fight the infection as well as supporting any body functions that the infection may have affected. The patient will be hospitalized and may be placed in an intensive care unit.
  • Oxygen - the patient will usually be given oxygen to support breathing.
  • Fluids - fluids will be administered to prevent dehydration and to bring blood pressure back up to normal.
  • Kidneys - a dialysis machine will be used if there is kidney failure. The machine filters toxins and waste out of the bloodstream.
  • Other damage - damage to skin, fingers or toes will need to be treated. This often involves draining and cleaning. In severe cases a body extremity or parts of skin may need to be surgically removed.
  • Antibiotics - a combination of antibiotics is administered intravenously (directly into the bloodstream).
  • Immunoglobulin - these are samples of donated human blood with high levels of antibodies which can fight the toxin. In some cases the medical team may administer immunoglobulin as well as antibiotics.
In the majority of cases the patient responds to treatment within a couple of days. However, he/she may have to stay in hospital for several weeks.

Preventing toxic shock syndrome

Before reading about possible preventive measures, it is important to remember that the risk of developing TSS is very low. A significant number of experts point to a probably link between tampon absorbency and TSS risk, and advise women to:
  • Thoroughly wash their hands before inserting a tampon
  • Use the lowest absorbency tampons for their period flow
  • Switch from tampons to sanitary towels (or panty liners) during their period
  • Change tampons at least as regularly as directed on the pack
  • Insert only one tampon at a time (never more than one)
  • Insert a fresh tampon when going to bed and replace it immediately in the morning
  • Remove the tampon as soon as the period has ended
The Mayo Clinic, USA, advises women to avoid using tampons completely when their flow is very light (use minipads instead).

The National Health Service (NHS), UK, advises that people who have had TSS should avoid using tampons.

Women who use a diaphragm, cap or contraceptive sponge should follow the manufacturer's instructions carefully (regarding how long to leave the device inside the vagina). The NHS advises women who have had TSS to use an alternative method of contraception.

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