Toxic shock syndrome (TSS) is a potentially fatal form of blood poisoning that is usually associated with a toxinproducing strain of the bacterium Staphylococcus aureus. It has been associated with the use of high-absorbency tampons during menstruation, but may also arise after surgery and as a consequence of severe burns.
In any form of shock, the circulation is impaired, blood pressure falls dramatically, and body organs begin to fail. Burns, severe blood loss, traumatic injury, and infections can cause shock, but in toxic shock the bacterial toxin is the underlying cause. Intensive care with rehydration and monitoring of vital functions such as respiration and blood pressure are necessary to treat a patient in shock. Toxic shock syndrome is a rare condition, and in its early stages may be confused with other illnesses. Prompt and accurate diagnosis of TSS is essential.
Most cases of toxic shock are caused by exposure to a toxin-producing strain of S. aureus, a normally harmless bacterium. S. aureus is normally present on the skin and in the nose, but some strains produce toxins that can cause toxic shock. The most common of these is known as toxic shock syndrome toxin, but others have been identified. The toxin invades the blood through some kind of ‘focus’ of infection, such as a post-operative wound, an intrauterine contraceptive device or a tampon used during menstruation. A few cases of toxic shock have been linked to Group A streptococcus or Streptococcus pyogenes, which also causes scarlet fever and necrotizing fasciitis, a deep tissue infection.
Symptoms of toxic shock come on very suddenly and include high fever, a sunburnlike rash, diarrhea, vomiting, fainting, dizziness, and confusion. There is a dramatic fall in blood pressure, which can lead to multiorgan failure affecting the liver, kidneys, heart, and brain. The fatality rate of toxic shock is between three and five percent. It can mimic other conditions, such as severe flu, in its earlier stages. One or two weeks after the illness, the skin on the palms and soles may start to peel off. Long-term complications of toxic shock include memory loss, decreased ability to concentrate, and emotional instability.
Toxic shock is rare, but the risk of TSS is greater among young people.
About half of all cases of toxic shock are associated with women using tampons, and the rest result from localized infections, usually following burns, boils, insect bites, or surgery. The presence of intrauterine contraceptive devices (IUDs) is also a risk factor for toxic shock.
Antibiotics can reduce the risk of recurrence of toxic shock but cannot always modify the course of the illness. Clindamycin, usually in combination with another anti-biotic, is often recommended, as it reduces the rate of production of toxin from S. aureus. Foreign bodies associated with the infection, such as a tampon, must be removed and infected wounds cleaned up.
Intensive care is generally needed to treat shock. The circulation and supply of oxygen to affected organs must be restored with rehydration therapy. Blood pressure, respiration, and other vital functions must be monitored constantly.
Women can avoid TSS associated with tampons by always using a tampon with the lowest possible absorbency and changing them regularly. It is never advisable to insert more than one tampon at a time, and the hands should be washed thoroughly before and after inserting a tampon. Women should also be sure to remove the final tampon when their period is over and not use tampons between periods.
WORDS TO KNOW
SHOCK: Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This condition deprives the organs and tissues of oxygen (carried in the blood) and allows the buildup of waste products. Shock can result in serious damage or even death.
TOXIC: Something that is poisonous and that can cause illness or death.
TOXIN: A poison that is produced by a living organism.
IN CONTEXT: TRENDS AND STATISTICS
According to the Division of Bacterial and Mycotic Diseases at Centers for Disease Control and Prevention (CDC): the “annual incidence (in the United States) is 1 in 2/100,000 women 15–44 years of age” and that “5% of all cases are fatal.” However the last active surveillance was performed in 1987.
Toxic shock is a rare condition and may not be readily recognized. The symptoms accompanying TSS, such as fever or rash, occur in many other illnesses. However, multi-organ failure can occur rapidly once the S. aureus toxin has entered the bloodstream; then, the patient's life may be in danger. Therefore, prompt medical attention is needed whenever there is a rapid onset of fever and other symptoms.
In 1980, an outbreak of TSS occurred among women who used a certain brand of tampon. Researchers traced most cases to use of the Rely superabsorbent tampon designed to be used over several hours or even days, though there were cases in women who used other superabsorbent brands. From March 1980 to March 1981, almost 1,000 U.S. women were diagnosed with TSS. Forty women died. When Rely and similar superabsorbent tampons were taken off the market, incidence of TSS dropped dramatically the following year. However, researchers noted that fewer women used any tampons immediately following the TSS outbreak. Today, tampons are designed to be changed more frequently, and women are encouraged to used tampons of varying absorbencies to match their menstrual flow. Tampons are now packaged and sold with informative literature about TSS and TSS prevention.
Wilks, David, Mark Farrington, and David Rubenstein. The Infectious Disease Manual. Malden: Blackwell, 2003.
Centers for Disease Control and Prevention (CDC). “Toxic Shock Syndrome.” October 24, 2005. <http://www.cdc.gov/ncidod/dbmd/diseaseinfo/toxicshock_t.htm> (accessed May 2, 2007).
The Toxic Shock Information Service. “Toxic Shock Syndrome: The Facts.” <http://www.toxicshock.com> (accessed May 2, 2007).