Toxic Shock Syndrome

What is toxic shock syndrome?

Toxic shock syndrome, or 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, implicated in this infection, 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 (the human immunodeficiency virus), 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 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 toxic shock syndrome may also occur from S. aureus infections 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 and cause TSS.

  • 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 or bacterial cellulitis (infection of the skin and underlying tissue).

What are the symptoms of toxic shock syndrome?

The following are the most common symptoms of TSS, however each person may experience symptoms differently. 

CDC criteria for Staphylococcus TSS include:

  • Fever of 102 degrees F or higher 

  • Chills

  • Malaise (uneasiness and despair)

  • Headache

  • Fatigue

  • Red, flat rash that covers most of the areas of the body

  • Shedding of the skin in large sheets, especially over the palms and soles (this 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 

CDC criteria for Streptococcus TSS include:

  • Dangerously low blood pressure

  • Shock

  • Decreased kidney function

  • Bleeding problems

  • Bruising due to low blood platelet count

  • Red, flat rash that covers large areas of the body

  • Liver problems

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

  • Difficulty breathing

The symptoms of TSS may resemble other medical conditions. Always consult your doctor for a diagnosis.

Who is at risk for streptococcal and staphylococcal TSS?

Streptococcal and staphylococcal TSS risks may include the following:

  • A 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 or abortion

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 studies may include:

  • Blood cultures. These tests are used to find and identify microorganisms.

  • Blood tests. These tests measure blood clotting and bleeding time, cell counts, electrolytes, and liver function, among others.

  • Urine tests.

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

What is the treatment for toxic shock syndrome?

Specific treatment for streptococcal and staphylococcal TSS will be determined by your doctor based on:

  • Your age, overall 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 people 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 can toxic shock syndrome be prevented?

The following may help prevent TSS:

  • 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, or sponges helps to reduce the risk of TSS. If a woman chooses to use tampons, she should change them frequently.