Infection: Toxic Shock Syndrome
Infection: Toxic Shock Syndrome
Toxic shock syndrome, or TSS, is a life-threatening illness caused by a bacterium called Staphylococcus aureus. A similar illness called toxic shock-like syndrome, or TSLS, is caused by another bacterium called Streptococcus pyogenes. Both illnesses are forms of sepsis, an inflammatory response of the entire body to severe infection.
Toxic shock syndrome, or TSS, was first given its present name by a pediatrician in Denver, Colorado, in 1978. He had been studying a case series of a severe illness caused by Staphylococcus aureus in a group of three boys and four girls between the ages of eight and seventeen. The doctor had been able to identify the bacterium in the tissues lining the noses, throats, or vaginas of the patients but not in their blood or urine samples. This finding led him to suspect that the symptoms of the illness—sudden high fever, shock, and a reddish rash resembling sunburn—were caused by a toxin produced by the bacteria. The doctor did not, however, suspect a connection between the illness and menstruation even though three of the four girls in his series had been using tampons at the time they fell ill.
The link between TSS in women and menstruation became clear in late 1979 and early 1980 following the introduction of a new type of tampon made from a superabsorbent type of cotton fiber combined with compressed beads of polyester. The new product was able to absorb 20 times its weight in fluid. By January 1980, doctors in Wisconsin and Minnesota were reporting cases of toxic shock syndrome in women using the new tampons, and doctors in other parts of the United States were reporting cases of TSS in women using other brands of highly absorbent tampons. The Centers for Disease Control and Prevention (CDC) began to investigate the reports and had the new tampon withdrawn from the market. By September 1980 the number of cases of TSS began to decline as women began to use sanitary napkins in place of tampons. According to CDC statistics, 942 women were diagnosed with tampon-related TSS in the United States from March 1980 to March 1981; forty of the women died.
It is now known that TSS can develop in males and in women who are not menstruating if they become infected with S. aureus following surgery or injury to the nasal passages. Patients with TSS develop a sudden high fever, a skin rash that looks like sunburn, a drop in blood pressure, and failure of multiple organ systems in the body.
Patients with toxic shock-like syndrome, caused by S. pyogenes, the same organism that causes strep throat, have similar symptoms. They are more likely to fall sick following a skin infection caused by S. pyogenes.
TSS related to menstruation is much less common in the United States than it was in the early 1980s. According to the Centers for Disease Control and Prevention (CDC), there were only five documented cases of toxic shock syndrome related to menstruation in 1997, compared to 814 in 1980. As of the early 2000s, the CDC estimates that between one and seventeen of every 100,000 menstruating women will get TSS.
Some people are at increased risk of TSS:
- Women who are menstruating
- Women who use diaphragms or other barrier methods of birth control
- People who are having surgery on the nose
- People with diabetes
- People with a weakened immune system
- People who have developed a staphylococcal infection following surgery
The cause of toxic shock syndrome is infection with S. aureus, while TSLS is caused by S. pyogenes. In both illnesses, the bacteria produce exotoxins—toxic substances released into the bloodstream—that overstimulate the body's immune system. As the immune system over-reacts to the exotoxins, the person goes into shock, a medical emergency in which the circula-tory system starts to shut down and deprives the body's tissues of blood. Without the oxygen and nutrients carried by the blood, the body's organs and tissues begin to fail.
A Survivor's Story
A Canadian woman thought that frequent changes of the high-absorbency tampons she used would be an adequate safeguard against toxic shock syndrome (TSS). However, the first Saturday in November 2004, she fell ill, stating, “[F]or some odd reason I knew it was TSS. I was vomiting all the time and knew it was more than a stomach bug. … My husband was taking care of me, following the doctor's instructions to keep me hydrated; give me nausea medication; and not to treat the diarrhea…. I don't remember much of that night, except extreme muscle pain, high fever and my mouth was so sore that I couldn't move my tongue without extreme pain. Every time I sat up I would black out. The next seven days were a blur of pokes, prods and doctors shaking their heads in confusion.”
She continued, “After a week in intensive care and recovery I was well enough to go home. Even though the skin was peeling off my palms and the soles of my feet (typical symptoms of TSS), the doctors still were ‘not sure’ what I'd had!” Her recovery was slow: she gained 40 pounds due to the fluid treatment, had decreased energy, weakness in her hands, extreme pain in her arms and wrists, her hair fell out in handfuls, and she needed antidepressants. In an update from 2006, her hair had finally grown back after a year of complete baldness, she was back to her normal weight, and she no longer needed antidepressants.
The symptoms of toxic shock syndrome include:
- Sudden high fever of 102°F (38.8°C) or higher
- Nausea and vomiting
- Low blood pressure
- Confusion and disorientation
- Sunburn-like rash that leads to peeling of the skin on the hands and feet after a week or so
- Sore, aching muscles
- Lightheadedness or dizziness when standing up
- Cramping or pain in the abdomen
- Redness in the eyes, mouth, and throat
- Large amounts of watery diarrhea
- Shock occurring about two days after the fever and other symptoms begin
The symptoms of TSLS are similar to those of toxic shock syndrome. In addition, patients with TSLS may have severe pain at the location of the skin infection that precedes TSLS.
There is no single test that is used to diagnose TSS or TSLS. The doctor will base the diagnosis on the patient's recent history and a set of criteria drawn up by the CDC to distinguish toxic shock syndrome from measles, Rocky Mountain spotted fever, or other similar diseases:
- Fever of 102.2°F (39°C) or higher.
- Systolic blood pressure below 90 mmHg (Systolic is the top number in a blood pressure reading.)
- Reddish rash followed by skin peeling
- Involvement of three or more of the following organs or organ systems: digestive tract; kidneys; liver; soft tissues lining the throat, nasal passages, or vagina; central nervous system; or the blood
TSS and TSLS are medical emergencies. The patient is taken at once to the hospital emergency department and tampons, nasal packing, or dressings covering a skin infection are removed. The doctor will usually order a blood test to evaluate liver function, kidney function, and the number of white blood cells present. A high white blood cell count, a high level of liver enzymes, and signs of abnormal kidney function suggest a diagnosis of TSS. The doctor will also check the patient's blood pressure, temperature, and heart rate. A female patient will usually be given a pelvic examination.
Treatment begins with locating the source of the infection (vagina, nose, throat, skin) and administering intravenous antibiotics. Depending on the patient's condition, he or she may be placed in an intensive care unit and given one or more of the following:
- Intravenous fluids to raise blood pressure and prevent dehydration
- Monitoring of kidney and liver function
- Dialysis in case of kidney failure
- Oxygen in case of breathing difficulties or lung failure
The prognosis for TSS is better than it was in the 1980s, partly because of earlier diagnosis and treatment. In 1980 the mortality rate for women with menstrual-related toxic shock syndrome was 13 percent; as of 2005, it was 3–5 percent. The mortality rate in other patient groups, however, can run as high as 30 percent, particularly if the infection is caused by S. pyogenes rather than by S. aureus.
Most patients with toxic shock syndrome or TSLS are sent home from the hospital after a week and recover fully in two to three weeks. The condition can be fatal within a few hours, however, if it is not treated promptly. About half of patients lose their hair and nails within two or three months after the illness, but these will usually grow back on their own.
About 50 percent of people treated for TSS or TSLS will develop recurrences between four and six months after the acute illness. These recurrences are not usually as serious as the first episode but must still be treated in the hospital.
The CDC recommends the following precautions to lower the risk of toxic shock syndrome or TSLS:
- Women of childbearing age should use low-absorbency tampons during their menstrual periods, change them every four to eight hours, or use sanitary napkins rather than tampons. Women who have had TSS or any serious staph or strep infection should not use tampons at all.
- People who have had nasal surgery should watch carefully for signs of infection, particularly if the nose has been packed with gauze or surgical dressings.
- Skin infections should be treated promptly.
- People who have had abdominal surgery, or women who have recently given birth, should also be monitored for signs of infection.
TSS and TSLS are fortunately very rare illnesses. Research is currently focused on understanding why some people develop toxic shock syndrome when most people exposed to S. pyogenes and S. aureus do not. These bacteria are very common in all parts of the world and can be found in the throats or on the skin of people who are not sick. Recent studies indicate that the majority of adults have antibodies in the blood that protect them against the bacterial exotoxins that cause TSS and TSLS, but scientists do not yet understand why a small number of people lack these antibodies.
SEE ALSO Scarlet fever; Staph infection; Strep throat
WORDS TO KNOW
Dialysis: A process in which the blood of a patient with kidney failure is cleansed of the body's waste products by being pumped through a machine that filters the blood and then returns it to the body.
Exotoxin: A toxin secreted by a bacterium or other disease organism into the body tissues of an infected individual.
Sepsis: The medical term for blood poisoning.
Shock: A medical emergency in which the body's tissues do not receive enough blood due to problems with the circulatory system.
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Centers for Disease Control and Prevention (CDC). “Epidemiologic Notes and Reports: Toxic Shock Syndrome—United States.” Morbidity and Mortality Weekly Report 46 (June 6, 1997): 492–495. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/00047818.htm (accessed July 14, 2008). This is a reprint of the first article published by the CDC on toxic shock syndrome on May 23, 1980. It was reprinted as part of the CDC's fiftieth anniversary commemoration.
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