Toxic Shock Syndrome

Toxic shock syndrome (TSS) is a rare, life-threatening illness that is caused by toxins (poisons) that circulate in the bloodstream. Bacteria that have infected some part of the body release these toxins. People with toxic shock syndrome develop high fever, rash, low blood pressure, and failure of multiple organ systems in the body.

Toxic shock syndrome was first found in children in 1978. However, toxic shock syndrome did not become familiar until an epidemic in 1981, linked to women using tampons.

Toxic shock syndrome is caused by toxins produced by bacteria. Only certain rare strains of specific bacteria produce these poisons. As the bacterial toxins are released into the bloodstream, they begin to overstimulate the immune system in the body. This, in turn, causes the severe symptoms of toxic shock syndrome.

In the most common form of toxic shock syndrome, the bacteria live in the vagina of women who are infected, and the bacterial growth is encouraged by the presence of a tampon. However, these toxins can be produced from bacteria in other locations in the body as well. Sometimes, the location of the infection is not clear.

• Staphylococcal toxic shock syndrome: Most cases of toxic shock syndrome are caused by a bacterium called Staphylococcus aureus. The most well-known form of staphylococcal toxic shock syndrome is associated with menstruating women using tampons. However, men, children, and nonmenstruating women can develop toxic shock syndrome as well. In fact, a third of all cases of toxic shock syndrome occur in men.


• Streptococcal toxic shock syndrome: Some cases of toxic shock syndrome are caused by Streptococcus pyogenes, the same bacterium that causes strep throat. S pyogenes often comes from a skin infection and causes a more serious form of toxic shock syndrome than S aureus.


• Possible sources of infection
  
  
  • Vagina (superabsorbent tampon use)
  
  
  • Nose (nasal packing)
  
  
  • Surgical wound
  
  
  • Childbirth
  
  
  • Any skin wound, such as those from chickenpox

Many people with toxic shock syndrome experience a 2- to 3-day period of mild symptoms before they develop the disease. These mild symptoms may include low-grade fever, muscle aches, chills, and malaise (a feeling of general discomfort, uneasiness, or ill health).

Toxic shock syndrome can affect most organ systems in the body, including the skin, lungs, liver, kidneys, blood, and pancreas. All people with toxic shock syndrome have a fever and a rash, as well as symptoms in at least 3 other organ systems. These symptoms or findings may include the following:

• Fever greater than 102°F (38.9°C)



• Rash (The rash of toxic shock syndrome is a red sunburnlike rash that covers most of the body. It is flat, not raised, and turns white if pressed. The rash may be difficult to see in dark-skinned people. Redness of the eyes, the lips, and the tongue [strawberry tongue] may also occur.)



• Headache (very common)



• Muscle aches



• Sore throat



• Cough



• Nausea and vomiting



• Diarrhea (profuse and watery)



• Abdominal pain



• Lightheadedness or fainting (especially on standing up)



• Confusion or disorientation



• Low blood pressure (systolic less than 90 mm Hg)

When to call the doctor

• Children
  
  
  • If a child has a fever and a red rash with some of the symptoms of toxic shock syndrome, call the doctor to discuss the possibility of toxic shock syndrome.
  
  
  • The most common causes of a fever and a rash in children are viruses and scarlet fever, which affect children younger than 10 years. Scarlet fever is a form of strep throat that causes a sore throat and a raised (bumpy) rash, not the flat rash of toxic shock syndrome. Scarlet fever is not usually a serious illness, and it is safe to wait until morning to call and visit the doctor.
  
  
  • If a child has severe nausea, vomiting, diarrhea, or all three, call the doctor to discuss the symptoms of dehydration.


• Adults
  
  
  • If a high fever is present without a rash, as well as some of the symptoms of toxic shock syndrome, call the doctor.
  
  
  • Many viral illnesses can cause fever and sore throat, cough, malaise, nausea and vomiting, diarrhea, and muscle aches.

When to go to the hospital

• Children: Take a child to the pediatrician or the hospital's emergency department if he or she has a fever, has a flat (not bumpy) rash, is not acting normally, seems confused, is short of breath, or faints.


• Adults: If fever is present with some of the toxic shock syndrome symptoms, along with a red rash, proceed to the hospital's emergency department for evaluation. Have someone else drive, especially if feeling lightheaded or confused. Women who are menstruating and using a tampon should remove the tampon prior to going to the hospital.

No specific test exists to help diagnose toxic shock syndrome. In the emergency department, the doctor usually starts by asking the person some questions about his or her symptoms over the past few days. Vital signs are taken, and the person is examined. If the doctor suspects toxic shock syndrome based on the physical exam, a few other procedures are performed. The person is connected to a heart monitor, and multiple IV lines are placed on the person.

• If the doctor suspects toxic shock syndrome, the following tests are performed:
  
  
  • Blood is drawn to check blood counts, electrolytes, and liver and kidney functions. An elevated white blood cell count, elevated liver enzymes, abnormal electrolytes, and abnormal kidney function may be consistent with toxic shock syndrome.
  
  
  • Women undergo a pelvic exam.
  
  
  • A chest x-ray film may reveal abnormalities, such as fluid in the lungs.
  
  
  • An electrocardiogram (ECG), which traces the electrical activity of the heart, may be performed.
  
  
  • Tests are likely performed to exclude other disease possibilities, such as Rocky Mountain spotted fever and measles.

|Self-Care at Home|

People with suspected toxic shock syndrome should be immediately taken to the hospital's emergency department. Women who are menstruating and using tampons should remove the tampon prior to going to the hospital.

|Medical Treatment|

People with toxic shock syndrome are admitted to the hospital's intensive care unit for treatment.

• The doctor tries to eliminate the source of infection with the following steps:
  
  
  • Remove the tampon or nasal packing
  
  
  
  • Search for any other possible source of infection
  
  
  
  • Start IV antibiotics


• The doctor helps support the functions of the body until the organs recover with the following steps:
  
  
  • Provide IV fluids and medications to raise the blood pressure
  
  
  
  • Correct electrolytes
  
  
  
  • Monitor kidney and liver functions
  
  
  
  • Provide oxygen if needed for breathing difficulty (Some people with severe lung failure need to have a tube inserted into their windpipe and be placed on a ventilator.)

|Medications|

• Antibiotics effective against S aureus and S pyogenes are given if toxic shock syndrome is suspected. These antibiotics may be changed later based on the results of the cultures. Initial antibiotics may include nafcillin, oxacillin, penicillin, and/or clindamycin.


• Medications to increase blood pressure may be given if blood pressure is low. These medications may include dopamine or epinephrine.

|Surgery|

• If the source of the infection is a tampon or other packing, removal of the tampon or packing is usually sufficient, and surgery is not necessary.


• If the source of the infection is in the skin, often no surgery is required. However, some instances arise when surgery is necessary to fully expose and drain a skin infection.


• If the infection is found to be in deeper tissues, extensive surgery is often necessary to remove the infected and dead tissue (called debridement).

|Follow-up|

• Skin effects
  
  
  • People who have toxic shock syndrome can expect their superficial skin to peel off about 1-2 weeks after the illness.
  
  
  
  • Half of those with toxic shock syndrome lose some or all of their hair and nails about 2-3 months after the illness. Hair and nails usually grow back on their own.


• Recurrence
  
  
  • Repeat episodes occur about 4-6 months after the initial episode in up to half of all people who have had toxic shock syndrome. These recurrences are usually not as dangerous but still must be taken seriously and treated in the hospital.

|Prevention|

• Women can prevent menstrual-related toxic shock syndrome by not using tampons, especially the superabsorbent variety.

• All wounds should be kept clean and monitored for signs of infection.

|Outlook|

Toxic shock syndrome is a serious, life-threatening disease. Early medical care is the key to ensuring the best possibility of survival. People who survive toxic shock syndrome usually improve within 48 hours and can be discharged from the hospital within 1 week.

• Staphylococcal toxic shock syndrome: Less than 5% of women with toxic shock syndrome caused by S aureus (including menstrual related) die.

• Streptococcal toxic shock syndrome: The form of toxic shock syndrome caused by S pyogenes is more severe and causes death in about 30% of people.

US Food and Drug Administration
5600 Fishers Lane
Rockville, MD 20857-0001
(888) INFO FDA (463-6332)

Centers for Disease Control and Prevention
1600 Clifton Rd
Atlanta, GA 30333
(800) 311-3435

|Web Links|

Centers for Disease Control and Prevention, Toxic Shock Syndrome

Centers for Disease Control and Prevention, Streptococcal Toxic-Shock Syndrome

MedlinePlus, Toxic shock syndrome

US Food and Drug Administration, TSS: Reducing the Risk

MayoClinic.com, Toxic shock syndrome

Media file 1: Toxic shock syndrome commonly causes a red strawberry tongue.

Media type:  Photo

Media file 2: This woman with toxic shock syndrome developed a flat, red, sunburnlike rash. This rash causes the skin to peel 1-2 weeks after the illness.

Media type:  Photo

toxic shock syndrome, TSS, toxins, staphylococcal TSS, streptococcal TSS, tampon usage, tampon use, Staphylococcus aureus, S aureus, Streptococcus pyogenes, S pyogenes, strep throat, vaginal infection, nasal infection, strawberry tongue, rash, menstruating females, menstruating women, menstruation, period, nafcillin, oxacillin, penicillin, clindamycin, dopamine, epinephrine

Author: Joseph S Bushra, MD, FAAEM, Adjunct Assistant Professor of Emergency Medicine, Temple University School of Medicine Philadelphia, PA, Attending Physician, Department of Emergency Medicine, The Lankenau Hospital Wynnewood, PA.

Editors: James Ungar, MD, Medical Director, Chair Department of Emergency Medicine Santa Rosa Memorial Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.