Toxic Shock Syndrome (TSS)

What is toxic shock syndrome?

Toxic shock syndrome (TSS) describes a cluster of symptoms that involve many systems of the body. The following bacteria commonly cause TSS:

• Staphylococcus aureus

• Streptococcus pyogenes

TSS from Staphylococcus infections was identified in the late 1970s and early 1980s when highly absorbent tampons were widely used by menstruating women. Due to manufacturing changes in tampons, the incidence of tampon-induced TSS has declined.

TSS from Streptococcus infections is most commonly seen in children and the elderly. Other populations at risk include individuals with diabetes, HIV, chronic lung disease, or heart disease.

How is toxic shock syndrome transmitted?

• Staphylococcus infections. Staphylococcus aureus (or S. aureus) may normally exist in a person's nose or vagina and does not cause infection. Because it is part of the body's normal bacteria, 90 percent of individuals develop antibodies to prevent infection. S. aureus can be transmitted by direct contact with infected persons. Individuals who develop TSS usually have not developed antibodies against S. aureus. Therefore, it is not usually considered a contagious infection. S. aureus infections may also occur from another infection, such as pneumonia, sinusitis, osteomyelitis (infection in the bone), or skin wounds, such as a burn or surgical site. If any of these areas are infected, the bacteria can penetrate into the bloodstream.

• Streptococcus infections. Streptococcus pyogenes (or S. pyogenes) TSS may occur as a secondary infection. Most commonly, this is seen in individuals who have recently had chickenpox, bacterial cellulitis (infection of the skin and underlying tissue), or have suppressed immune systems.

What are the symptoms of toxic shock syndrome?

Symptoms of TSS involve many systems and may resemble other infections. While each person may experience symptoms differently, the following are the most common symptoms of Staphylococcal TSS, according to the CDC:

• Fever higher than 38.9 degrees C or 102 degrees F

• Chills

• Malaise

• Headache

• Fatigue

• Rash that is red and flat and that covers most of the areas of the body

• Shedding of the skin in large sheets, especially over the palms and soles, which is seen one to two weeks after the onset of symptoms.

• Low blood pressure

• Vomiting

• Diarrhea

• Muscle pain

• Increased blood flow to the mouth, eyes, and vagina, making them appear red

• Decreased urine output and sediment in urine

• Decreased liver function

• Bruising due to low blood platelet count

• Disorientation and confusion

The following are the most common symptoms of Streptococcal TSS, according to the CDC:

• Dangerously low blood pressure

• Shock

• Decreased kidney function

• Bleeding problems

• Bruising due to low blood platelet count

• Rash that is red and flat and that covers most of the areas of the body

• Liver impairment

• Shedding of the skin in large sheets, especially over the palms and soles (this does not always occur)

• Difficulty breathing

What are the possible causes of TSS?

• History of using super-absorbent tampons

• Surgical wounds

• A local infection in the skin or deep tissue

• History of using the diaphragm or contraceptive sponge

• History of childbirth

How is toxic shock syndrome diagnosed?

Ruling out similar illnesses (such as Rocky Mountain Spotted Fever, among others) is critical in diagnosing TSS. In addition, confirmation is made in children and adults who meet the CDC criteria for TSS. Other diagnostic tests may include:

• Blood cultures. Tests used to find and identify microorganisms.

• Blood tests. Tests to measure blood clotting and bleeding times, cell counts, electrolytes, and liver function, among others.

• Urine tests.

• Lumbar puncture. A procedure involving the insertion of a needle in between the vertebrae of the spine to draw spinal fluid and check for bacteria.

What are the treatments for toxic shock syndrome?

Specific treatment will be determined by your health care provider based on:

• Your age, health, and medical history

• Extent of the disease

• Your tolerance for specific medications, procedures, or therapies

• Expectations for the course of the disease

• Your opinion or preference

Treatment for TSS may include:

• Administration of IV antibiotics

• Administration of intravenous fluid to treat shock and prevent organ damage

• Cardiac medications in patients with very low blood pressure

• Dialysis may be required in persons who develop kidney failure

• Administration of blood products

• Supplemental oxygen or mechanical ventilation to assist with breathing

• Deep surgical cleaning of an infected wound

How is toxic shock syndrome prevented?

• Since reinfection is common, menstruating girls and women should avoid using tampons if they have had TSS.

• Prompt and thorough wound care is crucial in avoiding TSS.

• Minimal usage of vaginal foreign body items, such as diaphragms, tampons, and sponges can also help prevent TSS.