Toxic shock syndrome

Definition

Toxic shock syndrome (TSS) is an uncommon but potentially serious illness that occurs when poisonous substances (toxins) produced by certain bacteria enter the bloodstream. The toxins cause a type of blood poisoning caused by staphylococcal, or less commonly streptococcal, infections in the lungs, throat, skin or bone, or from injuries. Women using super-absorbent tampons during menstruation were found to be most likely to get toxic shock syndrome.

Description

TSS first came to the attention of the public in the 1970s. Shortly after the introduction of a super-absorbent tampon, young women across the United States experienced an epidemic of serious but unexplained symptoms. Thousands went to emergency rooms with high fever, vomiting , peeling skin, low blood pressure, diarrhea , and a rash resembling sunburn . The only thing they had in common was that they all were menstruating at the time they felt sick, and all were using tampons—especially super-absorbent products.

At its height, the epidemic affected 15,000 people in the United States each year between 1980 and 1984; 15% of the women died. Since the offending products were taken off the market, the numbers of TSS cases have declined sharply. As of 1998, only about 5,000 cases are diagnosed annually in the United States, 5% of which are fatal. The decline is most likely due to the tampon manufacturers' discontinuing the use of some synthetic materials, and the removal from the market of the brand of tampon associated with most cases of TSS. As of the early 2000s, most of these products are made with rayon and cotton.

In spite of TSS's association with menstruating women, the disease can affect anyone of either sex or any age or race. The infection may occur in children, men, and non-menstruating women who are weakened from surgery, injury, or disease, and who cannot fight off a staphylococcal infection. New mothers are also at higher risk for TSS, particularly if they had a caesarean section or if they are breastfeeding their infants.

Most cases reported in Western countries still involve menstruating women under age 30. TSS still occurs in about 17 out of every 100,000 menstruating girls and women each year; more than half of these cases are related to tampons. Between 5% and 10% of patients with TSS die.

In the developing countries, however, toxic shock syndrome often affects children. A recent report of staphylococcal TSS from Saudi Arabia concerned a four-month-old infant. Burns appear to increase the risk of TSS in children in all countries.

Streptococcal toxic shock syndrome (STSS)

A new type of toxic shock syndrome is caused by a different bacterium, called Group A streptococcus. This form of TSS is called streptococcal toxic shock syndrome, or STSS. Officially recognized in 1987, STSS is related to the strain of streptococcus called the flesh-eating bacterium. STSS affects only one or two out of every 100,000 Americans. It almost never follows a simple strep throat infection.

In Europe and the United Kingdom, however, the incidence of streptococcal toxic shock syndrome has continued to rise through the 1990s. In one district in the United Kingdom, the annual rate rose from 1.1 cases per million population in 1990 to 9.5 cases per million by 1999. The fatality rate is 64%, even in healthy young adults.

Causes & symptoms

Transmission

STSS is caused by a strain of Streptococcus pyogenes found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the bloodstream, causing a potentially fatal infection.

While experts know the name of the bacterium, more than 10 years after the 1980s epidemic scientists still do not fully understand the link between TSS and tampons. Most medical researchers today suspect that the absorbent tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body. Oxygen triggers bacterial growth, and the more absorbent the tampon, the more bacteria it can harbor. Some experts believe that the reason TSS is linked to tampons in particular is that bacteria can contaminate and multiply in a tampon. If left in place for a long time—as a woman could do with a super absorbent product—the bacteria have a better chance of multiplying and producing a large amount of toxin. It is also possible that the tampons or the chemicals they contain may irritate the vaginal lining, enabling the toxin to enter the bloodstream.

These type of bacteria are normally present either on hands or in the vagina, and it takes an amount of bacteria only the size of a grain of sand to start an infection. Of the 15% of women who carry Staphylococcus aureus, only about 5% have the strain that produces the TSS toxin.

Symptoms

TSS. TSS begins suddenly, with a high fever of 102°F (38.9°C) or above, vomiting and watery diarrhea, headache , and sunburn-like rash; together with a sore throat and body aches. Blood pressure may plummet a day or two after the first symptoms appear. When the blood pressure drops, a woman may become disoriented or go into shock and her kidneys may fail. After these developments, the skin on her hands and feet may peel.

STSS. STSS can occur after a streptococcal infection in the body, usually from an infected wound or even chickenpox . Typically, within 48-96 hours, the patient's blood pressure drops. There is also fever, dizziness , breathing problems, and a weak, rapid pulse. The area around the wound may swell, the liver and kidneys can fail, and bleeding problems may occur.

Diagnosis

Any woman who is wearing a tampon and begins to experience the symptoms of toxic shock syndrome should remove the tampon right away and seek medical care.

The doctor will probably examine the vagina for signs of inflammation and rule out common sexually transmitted diseases with similar symptoms. A variety of blood tests, tests of vaginal secretions, and a physical examination are needed to identify this condition.

Treatment

Toxic shock syndrome is a life-threatening condition. If it is suspected, emergency medical attention should be sought immediately. Treatment with antibiotic drugs and IV fluids will be necessary.

Goldenseal, calendula , and echinacea can be applied topically. A diet low in sugar, with an increase in the consumption of vegetables and fruit helps to build the immune system. Movement therapies and exercise are also beneficial.

Allopathic treatment

TSS

In a menstruating woman, the vagina is first cleansed with an antiseptic solution to eliminate some of the bacteria that produce the toxin. TSS is treated with antibiotics, together with other drugs and fluids to lower fever and control blood pressure.

STSS

Antibiotics are used to treat STSS. Surgery may be needed to remove dead skin and muscle.

Expected results

TSS lasts as long as three weeks, and may have a tendency to recur. About a third of the women who are treated for TSS have it again within six months. In addition, TSS can affect the liver, kidneys, lungs, and other organs, depending on the severity of the infection. Untreated toxic shock syndrome can be fatal.

Prevention

TSS

Women who wear tampons should change them often and use different brands and types of pads and tampons. If a woman really prefers tampons, experts recommend using the lowest possible absorbency product made of cotton and rayon, and wearing it only during the day. In the past, it was difficult to compare absorbency rates for different products. Today, the Food and Drug Administration (FDA) requires standardized absorbency measurements on all tampon boxes. Above all, women should wash their hands before inserting a tampon, and change the tampon every four to six hours.

Anyone who has had TSS even once should not use tampons again.

KEY TERMS

Streptococcus

—A genus of sphere-shaped bacteria that can cause a wide variety of infections.

STSS

Doctors still are not sure how people can avoid STSS, but they advise patients to clean and bandage open wounds immediately. Anyone with a red, swollen, or tender wound, or a sudden fever should seek medical care.

Resources

BOOKS

Turkington, Carol A. Infectious Disease A to Z. New York: Facts on File, 1998.

PERIODICALS

Amir, L. "Breastfeeding and Staphylococcus aureus : Three Case Reports." Breastfeeding Review 10 (March 2002): 15-18.

Barnham, M. R., N. C. Weightman, A. W. Anderson, and A. Tanna. "Streptococcal Toxic Shock Syndrome: A Description of 14 Cases from North Yorkshire, UK." Clinical Microbiology and Infection 8 (March 2002): 174-178.

Ghazal, S. S., M. N. Al-Hawasi, S. A. Al-Mosallam, et al. "Staphylococcal Toxic Shock Syndrome in a Small Infant." Saudi Medical Journal 23 (February 2002): 229-231.

Johnson, D., and P. D. Panthirana. "Toxic Shock Syndrome Following Cessation of Prophylactic Antibiotics in a Child with a 2% Scald." Burns 28 (March 2002): 181-184.

"Toxic shock syndrome—United States." Morbidity and Mortality Weekly Report 46 (22) (June 6, 1997): 492-495.

Paula Ford-Martin

Rebecca J. Frey, PhD

Toxic Shock Syndrome

Definition

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness that occurs when poisonous substances (toxins) produced by certain bacteria enter the bloodstream. The toxins cause a type of blood poisoning caused by staphylococcal, or less commonly streptococcal, infections in the lungs, throat, skin or bone, or from injuries. Women using super-absorbent tampons during menstruation were found to be most likely to get toxic shock syndrome.

Description

TSS first came to the attention of the public in the 1970s. Shortly after the introduction of a super-absorbent tampon, young women across the United States experienced an epidemic of serious but unexplained symptoms. Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. The only thing they had in common was that they all were menstruating at the time they felt sick, and all were using tampons, especially super-absorbent products.

At its height, the epidemic affected 15,000 people in the United States each year between 1980 and 1984; 15% of the women died. Since the offending products were taken off the market, the number of TSS cases has declined sharply. As of 1998, only about 5,000 cases are diagnosed annually in the United States, 5% of which are fatal. The decline most likely is due to tampon manufacturers discontinuing the use of some synthetic materials, and the removal from the market of the brand of tampon associated with most cases of TSS. Today, most of these products are made with rayon and cotton.

In spite of TSS' association with menstruating women, the disease can affect anyone of either sex or any age or race. The infection may occur in children, men, and non-menstruating women who are weakened from surgery, injury, or disease, and who cannot fight off a staphylococcal infection. New mothers also are at higher risk for TSS.

Most cases reported in the recent past, however, still involve menstruating women under age 30. TSS still occurs in about 17 out of every 100,000 menstruating girls and women each year; more than half of these cases are related to tampons. Between five and 10% of patients with TSS die.

Streptococcal toxic shock syndrome (STSS)

A new type of toxic shock syndrome is caused by a different bacteria, called Group A streptococcus. This form of TSS is called streptococcal toxic shock syndrome, or STSS. Officially recognized in 1987, STSS is related to the strain of streptococcus nicknamed the "flesh-eating bacterium." STSS affects only one or two out of every 100,000 Americans. It almost never follows a simple strep throat infection.

Causes and symptoms

Transmission

TSS is caused by a strain of Staphylococcus aureus found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the bloodstream, causing a potentially fatal infection.

While experts know the name of the bacterium, more than 10 years after the 1980s epidemic scientists still do not fully understand the link between TSS and tampons. Most medical researchers today suspect that the absorbent tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body. Oxygen triggers bacterial growth, and the more absorbent the tampon, the more bacteria it can harbor. Some experts believe that the reason TSS is linked to tampons in particular is that bacteria can contaminate and multiply in a tampon. If left in place for a long time—as a woman could do with a super-absorbent product—the bacteria have a better chance of multiplying and producing a large amount of toxin. It also is possible that the tampons or the chemicals they contain may irritate the vaginal lining, enabling the toxin to enter the bloodstream.

These types of bacteria normally are present either on hands or in the vagina, and it takes an amount of bacteria only the size of a grain of sand to start an infection. Of the 15% of women who carry Staphylococcus aureus, only about 5% have the strain that produces the TSS toxin.

Symptoms

TSS. TSS begins suddenly, with a high fever of 102°F (38.9°C) or above, vomiting and watery diarrhea, headache, and sunburn-like rash, together with a sore throat and body aches. Blood pressure may plummet a day or two after the first symptoms appear. When the blood pressure drops, a woman may become disoriented or go into shock. Her kidneys may fail. After these developments, the skin on her hands and feet may peel.

STSS. STSS can occur after a streptococcal infection in the body, usually from an infected wound or even chickenpox. Within 48 hours, the patient's blood pressure drops. There also is fever, dizziness, breathing problems, and a weak, rapid pulse. The area around the wound may swell, the liver and kidneys can fail, and bleeding problems may occur.

Diagnosis

Any woman who is wearing a tampon and begins to experience the symptoms of toxic shock syndrome should remove the tampon right away and seek medical care.

The doctor will probably examine the vagina for signs of inflammation and rule out common sexually transmitted diseases with similar symptoms. A variety of blood tests, tests of vaginal secretions, and a physical examination are needed to identify this condition.

Treatment

TSS

In a menstruating woman, the vagina first is cleansed with an antiseptic solution to eliminate some of the bacteria that produce the toxin. TSS is treated with antibiotics, together with other drugs and fluids to lower fever and control blood pressure.

STSS

Antibiotics are used to treat STSS. Surgery may be needed to remove dead skin and muscle. Research continues on new therapy options to help improve treatment of STSS, including intravenous therapy with immunoglobulin. The therapy doesn't replace use of antibiotics but works along with it.

Prognosis

TSS lasts as long as three weeks, and has a tendency to recur. About a third of the women who are treated for TSS have it again within six months. In addition, TSS can affect the liver, kidneys, lungs, and other organs, depending on the severity of the infection. Untreated toxic shock syndrome can be fatal. A 2003 report noted that a quick diagnosis of TSS is critical to avoiding serious complications and death.

KEY TERMS

Shock— A condition in which the amount of blood circulating in the body is inadequate to meet the body's needs. Shock can be caused by certain diseases, serious injury, or blood loss.

Staphylococcus — A genus of bacteria that is commonly found on human skin and mucous membranes.

Streptococcus — A genus of sphere-shaped bacteria that can cause a wide variety of infections.

Toxin— A poisonous protein that is produced by some bacteria. A toxin is less complex than a poison.

Prevention

TSS

Women who wear tampons should change them often and use different brands and types of pads and tampons. If a woman really prefers tampons, experts recommend using the lowest possible absorbency product made of cotton and rayon, and wearing it only during the day. In the past, it was difficult to compare absorbency rates for different products. Today, the Food and Drug Administration (FDA) requires standardized absorbency measurements on all tampon boxes. Above all, women should wash their hands before inserting a tampon, and change the tampon every four to six hours.

Anyone who has had TSS even once should not use tampons again.

STSS

Doctors still are not sure how people can avoid STSS, but they advise patients to clean and bandage open wounds immediately. Anyone with a red, swollen, or tender wound, or a sudden fever should seek medical care.

Resources

PERIODICALS

"A Quick Diagnosis of Toxic Shock Syndrome Is Critical for Avoiding Mortality." Health & Medicine Week December 1, 2003: 616.

"Toxic Shock Syndrome May Be Treatable with IVIG Therapy." Blood Weekly October 2, 2003: 64.

OTHER

Kids Health Page. 〈http://KidsHealth.org〉.

Toxic shock syndrome

Definition

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness that occurs when poisonous substances (toxins) produced by bacteria enter the bloodstream. The toxins cause a type of blood poisoning that results in high fever , symptoms of shock, and potentially organ failure.

Description

Initially toxic shock syndrome was associated with the use of ultra-absorbent tampons by menstruating girls and women. Between 1978 and 1980 thousands went to emergency rooms with high fever, vomiting , low blood pressure, diarrhea , and a rash resembling sunburn . Once ultra-absorbent tampons were taken off the market, the number of cases of toxic shock syndrome decreased substantially.

As of 2004, two different causes of toxic shock were recognized. Staphylococcal toxic shock syndrome (TSS) is caused by the bacteria Staphylococcus aureus. Streptococcal toxic shock syndrome (STSS, first described in 1987, is caused by Streptococcus pyogenes bacteria. Although both types of toxic shock are rare, STSS is more common and has a higher rate of serious complications and death.

Transmission

TSS is caused by a strain of S. aureus found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the bloodstream, causing a potentially fatal reaction.

Although scientists still do not fully understand the link between TSS and tampons, most medical researchers suspect that tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body. Oxygen triggers bacterial growth, and the more absorbent the tampon, the longer it is left in place and the more toxin-producing bacteria it can harbor.

The streptococcal bacteria that cause STSS often enter the body through an infected wound in the skin, infection following surgery, postpartum or post abortion infection, or bone infection. STSS almost never develops following a simple strep throat infection.

Demographics

Although the majority of cases of TSS occur in menstruating girls and women, the disease may occur in people of any race and age, including children. STSS infection may occur in individuals who are weakened from surgery, injury, or disease that weakens the immune system. New mothers also are at higher risk for toxic shock syndrome, as are those who have recently had chicken pox. This disease is rare. Only about 100 cases of TSS and 300 cases of STSS were reported in the United States in 1996.

Causes and symptoms

Toxic shock syndrome begins suddenly about two days after infection occurs with a fever of 102°(38.9°C) or above, vomiting and watery diarrhea, headache , and sunburn-like rash, together with a sore throat and body aches. Blood pressure may plummet a day or two after the first symptoms appear. When blood pressure drops, an individual may become disoriented or go into shock. The kidneys or liver may fail. After these developments, the skin on the hands and feet may peel. With STSS, flesh around the infected site may become damaged and die (become necrotic).

When to call the doctor

Toxic shock is a medical emergency that needs to be treated immediately in the hospital. Parents should go to the emergency room or call an ambulance if their child has a fast, weak pulse; cold hands and feet with pale moist skin; mental confusion or lethargy; abnormal breathing; a sunburn-like rash; high fever; or skin that is red, swollen, and infected.

Diagnosis

Diagnosis is made based on history, presenting symptoms, and culture of bacteria from the blood or wound. A rapid streptococcal test can be done with results available in 15 minutes. This test is positive in more than 85 percent of cases of toxic shock.

Treatment

Because toxic shock is a medical emergency, treatment is usually begun before laboratory results are available. The first line of treatment is to attempt to reverse the symptoms of shock. This process usually involves the administration of fluids intravenously. The site of infection is cleaned, and antibiotics are administered. If organ failure occurs, oxygen, the use of a respirator, or kidney dialysis may be necessary. It may also be necessary to surgically remove any infected and dying tissue.

Prognosis

Many otherwise healthy individuals recover from toxic shock in two to three weeks; however, the length of recovery is variable and depends on how early and how aggressively the disease is treated. About 3 percent of individuals with TSS die. The death rate with STSS can be as high as 30 to 70 percent.

Prevention

Women and girls who use tampons should always wash their hands before inserting a tampon and change the tampon every four to six hours. Skin wounds should be cleaned with an antiseptic and covered with a bandage.

Parental concerns

Although the risk of TSS is very low, parents may prefer that their daughters use pads rather than tampons when menstruating.

KEY TERMS

Shock —A medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen and allows the build-up of waste products. Shock can be caused by certain diseases, serious injury, or blood loss.

Staphylococcal infection —Infection with one of several species of Staphylococcus bacteria. Staphylococcal infections can affect any part of the body and are characterized by the formation of abscesses. Also known popularly as a staph infection.

Streptococcus —Plural, streptococci. Any of several species of spherical bacteria that form pairs or chains. They cause a wide variety of infections including scarlet fever, tonsillitis, and pneumonia.

Toxin —A poisonous substance usually produced by a microorganism or plant.

Resources

BOOKS

Marx, John. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby, 2002.

PERIODICALS

"A Quick Diagnosis of Toxic Shock Syndrome Is Critical for Avoiding Mortality." Health & Medicine Week (December 1, 2003): 616.

WEB SITES

Sharma, Sat, and Godfrey Harding. "Toxic Shock Syndrome." eMedicine Medical Library, January 22, 2003. Available online at <www.emedicine.com/med/topic2292.htm> (accessed October 4, 2004).

Tish Davidson, A.M.

Toxic shock syndrome

Toxic shock syndrome is an illness caused by the bacterium Staphylococcus aureus. The syndrome was first recognized in the 1970s when women who were wearing a "superabsorbant" tampon for their menstrual flow developed the illness. The majority of cases occur with this population. Less frequently, toxic shock syndrome can occur in females who do not use tampons, as well as in males.

The symptoms of toxic shock syndrome are caused by a toxin that is produced by Staphylococcus aureus. The exact nature of the association of the bacterial growth in superabsorbant tampons and the production of the toxin remains unclear. Whatever the exact cause, the cell-density behavior of other bacteria lends support to the suggestion that toxin production is triggered by the accumulation of large numbers of the bacteria. In the syndrome occurring in males or women who do not use tampons, there is usually a staphylococcal infection present in the body.

The symptoms of toxic shock syndrome include a sudden high fever, nausea with vomiting, diarrhea, headache, aches all over the body, dizziness and disorientation, a sunburn-like rash on the palms of the hands and the soles of the feet, and a decrease in blood pressure. The latter can send a victim into shock and can result in death. Those who recover may have permanent kidney and liver damage.

These symptoms are produced by the particular toxin that is released by the bacteria. The toxin can enter the bloodstream and move throughout the body. The toxin has been called a "superantigen" because of its potent stimulation of cells of the immune system . The immune cells release a compound called cytokine. Normally, only a small proportion of the immune cells are releasing cytokine. But the massive cytokine release that occurs in response to the staphylococcal toxin produces the myriad of physiological changes in the body.

Treatment of toxic shock syndrome depends on the prompt recognition of the symptoms and their potential severity. Immediate administration of antibiotics is essential.

The number of cases of toxic shock syndrome has been reduced since the suspect superabsorbant tampons were withdrawn from the marketplace.

See also Bacteria and bacterial infection; Enterotoxin and exotoxin; Immune system

TOXIC SHOCK SYNDROME

TOXIC SHOCK SYNDROME (TSS), a rare, sometimes fatal disease that caused widespread panic among women during the early 1980s when the Centers for Disease Control (CDC) and other public health organizations linked the growing number of cases of TSS with the increasing popularity of high-absorbency tampons. The earliest reported cases of TSS occurred among seven children in 1978 and were linked with the presence of Staphylococcus aureus. Symptoms of the disease include vomiting, diarrhea, high fever, and sunburnlike rash. Fatalities among early TSS patients were around 8 percent. In 1980,890 cases were reported to the CDC, 812 of which were among women whose illness coincided with the start of their menstrual periods. When the Utah Department of Health collected information suggesting that women with TSS had used a particular tampon brand, Rely, the CDC devised a study to examine tampon brand use. The study found that 71 percent of a test group of women with TSS had used Rely tampons. On 22 September 1980, Procter and Gamble recalled all Rely tampons on the market and all tampon manufacturers subsequently lowered the absorbency of their tampons. The Food and Drug Administration began requiring that all tampon packages carry information on TSS, advising women to use tampons with the minimum absorbency needed and to change tampons frequently. Though the scare associated menstruating women with TSS, the disease has been reported in men, children, and older women and in conjunction with surgery, influenza, sinusitis, childbirth, intravenous druguse, cuts, boils, abscesses, insect bites, and the use of contraceptive sponges, cervical caps, and diaphragms.

BIBLIOGRAPHY

Donawa, Maria E. et al. "Toxic Shock Syndrome: Chronology of State and Federal Epidemiologic Studies and Regulatory Decision-Making." Public Health Reports 99 (1984).

Etheridge, Elizabeth W. Sentinel for Health: A History of the Centers for Disease Control. Berkeley: University of California Press, 1992.

Sapolsky, Harvey M., ed. Consuming Fears: The Politics of Product Risks. New York: Basic Books, 1986.

Suzanne WhiteJunod/f. b.

See alsoCenters for Disease Control and Prevention ; Epidemics and Public Health ; Microbiology ; Women's Health .

toxic shock syndrome (TSS). acute, sometimes fatal, disease characterized by high fever, nausea, diarrhea, lethargy, blotchy rash, and sudden drop in blood pressure. It is caused by Staphylococcus aureus, an exotoxin-producing bacteria (see toxin ); group A streptococcus cause a similar disease, called streptococcal toxic shock syndrome or toxic shock-like syndrome. Toxic shock was initially identified among menstruating women using high-absorbency tampons that contained synthetic materials, now no longer used, that bound and removed magnesium from the surrounding bodily environment. The resulting lower magnesium levels encouraged bacterial exotoxin production. Slightly more than half of all cases now occur in menstruating women; nonmenstruating women, men, and children may also develop TSS, as a result of infection after surgery and other causes. Treatment mainly involves supportive measures, such as intravenous fluids and, if necessary, kidney dialysis, but may include antibiotics and immunoglobulin.

TOXIC SHOCK SYNDROME

DEFINITION

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness. It almost always occurs in women using super-absorbent tampons during menstruation, but researchers are still not entirely clear what the connection is between this kind of tampon and TSS.

DESCRIPTION

Toxic shock syndrome first came to public attention in the 1970s when thousands of young women began to go to emergency rooms with a common set of symptoms. Those symptoms included high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. Most of these women had one thing in common: they were all menstruating. And the majority were using a new type of tampon called a super-absorbent tampon.

The epidemic reached its peak between 1980 to 1984. During that period, about fifteen thousand people a year were diagnosed with TSS. About 15 percent of those who got the disease died of it.

Doctors were not certain what the connection was between TSS and super-absorbent tampons, but it was obvious that some connection existed. Tampon manufacturers were encouraged to discontinue the product and when the manufacturers did, the number of TSS cases began to fall dramatically. Since 1998, only about 5,000 cases of TSS are diagnosed annually. The death rate has fallen to about 5 percent.

For many years, TSS has been thought of as a woman's disease because of the connection between TSS and tampons. And while TSS is largely a disease that affects menstruating women under the age of thirty, individuals of either sex, any age, and any race or ethnic group can get disease.

Streptococcal Toxic Shock Syndrome (STSS)

The form of toxic shock syndrome first seen in the 1970s is caused by a group of bacteria known as Staphylococcus aureus (pronounced STAFF-uhloh-kock-us AW-ree-us). In 1987 a new form of TSS was discovered that is caused by a different bacterium that belongs to the Streptococcus (pronounced strep-tuh-KOK-us) family.

CAUSES

The Staphylococcus bacterium that causes toxic shock syndrome is found in the nose and mouth and, less often, the vagina. The bacterium releases a toxin (poison) that can get into the bloodstream. The toxin can cause an infection that is potentially fatal.

Researchers are still not certain as to how tampons promote the growth of Staphylococcus bacteria. One theory is that the tampons trap oxygen, which bacteria need to survive. Oxygen normally is not present in the vagina in large amounts. Another theory is that tampons provide a warm, moist environment that encourages the growth of bacteria. Yet another theory places the blame for TSS on the material of which the tampons were made. This theory suggests that the material irritated the vaginal lining. Sores on the vagina may have made it easier for bacterial toxins to get into the bloodstream.

Toxic Shock Syndrome: Words to Know

Shock:

A sudden drop in blood supply and oxygen provided to the body's tissues.

Staphylococcus :

A class of bacteria found on human skin and mucous membranes that can cause a variety of infectious diseases.

Streptococcus :

A class of bacteria that causes a wide variety of infections.

Tampon:

A cloth pad worn in the vagina to absorb fluids released during menstruation.

SYMPTOMS

Toxic shock syndrome begins suddenly with a fever of 102° F (38°C) or more. Other symptoms include vomiting, a watery diarrhea, headache, and a sunburn-like rash. Blood pressure may drop quickly. When this happens, the patient may become confused or go into shock. The kidneys may fail. Later, the skin on hands and feet may peel.

Streptococcal toxic shock syndrome (STSS) is characterized by fever, dizziness, breathing problems, and a weak, rapid pulse rate. The patient's blood pressure drops suddenly and dramatically.

DIAGNOSIS

Any woman who is wearing a tampon and experiences the described symptoms should remove the tampon at once seek medical advice.

In diagnosing TSS, the first step taken by a doctor may be ruling out other diseases. For example, an examination of the vagina may be needed to rule out sexually transmitted diseases (see sexually transmitted diseases entry). Blood tests or a vaginal smear can then determine the presence of the bacteria that cause either TSS or STSS. In a vaginal smear, a small amount of vaginal fluids is removed with a cotton swab. The fluid can then be examined under a microscope to determine if the bacteria that cause TSS and STSS are present.

TREATMENT

Both TSS and STSS are bacterial infections. They can both be treated, therefore, with antibiotics, drugs that fight bacteria. The vagina may also be cleaned to remove bacteria that cause the two diseases.

PROGNOSIS

When treated promptly and correctly, both TSS and STSS can be cured. TSS tends to recur within a period of about six months. The bacteria that cause the two diseases can also spread to other parts of the body and can produce complications in the liver, kidneys, lungs, and other organs. Untreated toxic shock syndrome can be fatal.

PREVENTION

Recommendations for preventing toxic shock syndrome usually involve instructions about the use of tampons. Experts recommend that women select products with the lowest possible absorbency. They also suggest that tampons be worn only during the day and that they be changed every four to six hours. Above all, women should wash their hands before inserting a tampon. Anyone who has had TSS even once should not use tampons again.

FOR MORE INFORMATION

Books

Barrett, Laurie. The Coming Plague. New York: Penguin Books, 1994.

Starr, Carolina V. Toxic Shock Syndrome. San Francisco, CA: Permeable Press, 1996.

Turkington Carol A. Infectious Disease A to Z. New York: Facts on File, 1998.

Toxic Shock Syndrome

What Is Going On?

What Is Toxic Shock?

How Does a Person Get Toxic Shock?

Signs and Symptoms

Diagnosis

How Is TSS Treated?

Can TSS Be Prevented?

Resources

Toxic shock syndrome (TSS) is an uncommon but sometimes life-threatening form of bacterial poisoning usually associated with Staphylococcus or Streptococcus bacteria.

KEYWORDS

for searching the Internet and other reference sources

Blood poisoning

Septicemia

What Is Going On?

Between October 1979 and May 1980, doctors all over the United States began reporting a new illness to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. Fifty-five women between the ages of 13 and 52 had shown up with symptoms of serious infections. The cooperation of doctors, health officials, epidemiologists, and laboratory scientists in the months that followed revealed a surprising coincidence—all the women were menstruating and used tampons*. This discovery led to recommendations that reduced the risk for the illness.

* tampon

is a plug of cotton or other material placed in the vagina during menstruation to absorb menstrual blood and other fluids.

What Is Toxic Shock?

Bacteria are microscopic one-celled organisms found all over the earth. Many bacteria play a beneficial role in producing antibiotics and nutrients such as vitamins for use by humans, plants, and animals. Bacteria are also essential ingredients in foods such as yogurt and sauerkraut. But bacteria can also cause disease. Staphylococcus aureus (staf-i-lo-KOK-us AW-ree-us) is a bacterium that normally lives harmlessly on the skin and in the nose, armpit, groin, or vagina*, but which can cause disease under certain circumstances.

* vagina

In girls and women, the vagina is the canal that leads from the uterus—the womb (the organ where a baby develops)— to the outside of the body.

For reasons that no one understands, certain forms of bacteria sometimes produce, or secrete, poisonous substances called toxins. People whose bodies are not equipped to fight these toxins may develop a severe reaction to them called toxic shock syndrome. In human beings, the toxin does not poison the cells directly. Instead, it stimulates the immune cells—the body’s defenders against disease—to secrete huge amounts of cytokines (Sl-to-kines), which are proteins that act on other cells. The action of these cytokines produces the symptoms of TSS.

A second kind of TSS, caused by Streptococcus (strep-to-KOK-us) bacteria and called STSS, was officially recognized in 1987. This illness behaves similarly to TSS and is treated in the same way, but it is much rarer and is related to injured skin and wounds, not to tampon use.

How Does a Person Get Toxic Shock?

Anyone—men, women, and children—can get TSS. TSS is not contagious like the cold or flu, but a person who has the bacteria on his or her hands can infect areas of broken skin or wounds anywhere on the body. Half of TSS cases involve women who use tampons during menstruation* or who have had injuries to the vagina from other causes, and half are related to infections arising from burns, insect bites, chickenpox blisters, or wounds resulting from surgery.

* menstruation

(men-stroo-AY-shun) refers to the monthly flow, or discharge, of the blood-enriched lining of the uterus that occurs in women who are old enough to bear children. Most girls have their first period between the age of 9 and 16. Menstruation ceases during pregnancy and after menopause.

Signs and Symptoms

TSS begins with vomiting, a high fever, diarrhea, and muscle aches. A sunburn-like rash develops over the body during the first two days of illness. Curiously, the place on the body where the bacteria are multiplying and producing toxin may appear perfectly normal. The early signs and symptoms of TSS go away within a few days. As the rash heals, the skin on the torso, face, hands, and feet begins to peel. Later symptoms may include low blood pressure and heart and kidney failure. Most people with TSS recover in 7 to 10 days, but 3 percent of people who get TSS die from it. People are more likely to die from TSS that is unrelated to menstruation.

Introducing Staphylococcus aureus

The staphylococci were among the first human disease-causing organisms to be discovered. They grow in various shapes, including irregular bulky clusters from which they get their name (the Greek word staphulé means “grapelike”). Staphylococci are the most common causes of infections that people get in hospitals. In fact, they are at the root of about 2 million hospital infections each year. There are various kinds of staphylococci. Some are particularly dangerous to people whose systems are already weak from other diseases. Staphylococcus aureus, the bacterium that causes TSS, is a major public health worry because it is very destructive and the infections it causes can be hard to treat.

Diagnosis

The early symptoms of TSS may resemble those of severe allergic drug reactions or other illnesses. Lacking any other explanation, a doctor will suspect TSS in certain patients, such as women who use vaginal methods of birth control (for example, a diaphragm) or anyone who has recently had an operation. A blood test can confirm the diagnosis.

How Is TSS Treated?

Hospitalization is usually recommended for TSS. Doctors treat TSS with antibiotics and anti-inflammatory drugs. The place on the body where the toxin is being produced is disinfected. During the worst part of the illness, a person is given fluids to maintain normal blood pressure, a breathing machine (ventilator) may be required, and if the kidneys fail, waste products may have to be removed from the blood in a procedure called dialysis (di-AL-a-sis).

Can TSS Be Prevented?

There is no sure way to prevent TSS, but women can take precautions against it. Menstruating women should avoid using superabsorbant tampons, change tampons frequently, and never leave a tampon inserted overnight. They also should wash their hands before and after inserting tampons. Girls and women who have had TSS should check with their doctor before using tampons again.

See also

Bacterial Infections

Shock

Resources

Books

Dusenberry, David B. Life at Small Scale: The Behavior of Microbes. New York: W. H. Freeman, 1996.

Snedden, Robert, and Steve Parker. Yuckl A Big Book of Little Horrors. New York: Simon and Schuster, 1996.

Organization

Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, N.E., Atlanta GA 30333. The United States government authority for information about infectious and other diseases. http://www.cdc.gov

Naming Bacteria

Bacteria, like all other organisms, are named by a pair of Latin words that identify them in the same way that a person’s name identifies him or her. For organisms, the family name is called the genus, and the first name, or given name, is called the species. So, for example, some members of the genus Staphylococcus are named Staphylococcus aureus, Staphylococcus epidermidis, and Staphylococcus saprophyticusto distinguish them from one another. Like members of a family, they are all related, but each acts in a different way.

Tutorials

“Introduction to the Bacteria.” An engaging, easy-to-read primer on bacteria, with very good links. http://www.ucmp.berkeley.edu/bacteria/bacteria.html

“Toxic Shock Syndrome.” A guide to toxic shock syndrome for parents and children from the experts at the Nemours Foundation. http://www.kidshealth.org/parent/common/toxic_shock.html

toxic shock syndrome (TSS) n. a state of acute shock due to septicaemia. The commonest cause is a retained foreign body (e.g. a tampon or IUCD) combined with the presence of staphylococci. The condition can be life-threatening if not treated aggressively with appropriate antibiotics and supportive care (including fluid and electrolyte replacement). streptococcal t. s. s. a similar condition caused by Type A streptococci. See also necrotizing fasciitis.

toxic shock syndrome Potentially fatal condition in which there is a dangerous drop in blood pressure and rapid onset of fever, diarrhoea, vomiting, and muscular pains. It is caused by blood poisoning (septicaemia) arising from toxins put out by bacteria that normally reside in the body without causing harm. The syndrome is most often seen in young women using tampons during menstruation.