Toxic Shock Syndrome

Toxic shock syndrome, or TSS, is an acute, life threatening condition that affects 1 in 100,000. TSS primarily affects young individuals. In the early convalescent period, it's characterized by fever, hypotension, rash, multiorgan dysfunction, and desquamation.

TSS from Staphylococcus infections was identified in the late 1970s and early 1980s when highly absorbent tampons were widely used in menstruating women. Due to manufacturing changes in tampons, the incidence of tampon-induced TSS has diminished by more than 40 percent. TSS from streptococcus infections is most commonly seen in children and the elderly. Other populations at risk include individuals with diabetes, HIV, chronic lung disease, or cardiac disease.

Causes and pathophysiology

Toxic shock syndrome is caused by penicillin-resistant Staphylococcus aureus, which produce exoproteins that are toxic in nature. TSST-1 is the toxin most often detected, and staphylococcal enterotoxin B is second most frequent.

For illness to develop, the patient must be infected with a toxigenic strain of S. aureus and lack antibodies to that strain. More than 90% develop antibodies by adulthood.

Menstruation is the most common setting for TSS occurrence, but half of all cases occur in settings other than menstruation and individuals of both sexes and all ages can be affected. Although tampons are clearly implicated in this infection, their exact role is uncertain. They may contribute to the infection by:

• introducing S. aureus into the vagina during insertion
• absorbing toxin from the vagina
• traumatizing the vaginal mucosa during insertion, thus leading to infection
• providing a favorable environment for growth of S.aureus.

Signs and symptoms

Symptoms of TSS include flu-like symptoms, which develop quickly and are severe. Symptoms may include: pain at the site of infection, vomiting and diarrhea, signs of shock including low blood pressure and light-headedness, headache, shortness of breath and sunburn-like rash.

Symptoms usually develop in 3 to 5 days in women who are menstruating and using tampons. In general, TSS symptoms can develop as soon as 12 hours after a surgical procedure.

Diagnostic tests

In addition to meeting CDC criteria for toxic shock syndrome and STSS, other diagnostic tests may include:

• blood cultures
• blood tests
• urine tests

Toxic shock syndrome diagnosis is confirmed if all 5 CDC clinical criteria are fulfilled. A probable case fulfils 4 of the 5 criteria.

Treatment

Appropriate treatment may consist of I.V. antistaphylococcal antibiotics, such as clindamycin oxacillin, nafcillin, and methicillin. To reverse shock, the patient needs fluid replacement with saline solution and colloids.

Sustained hypotension that is unresponsive to fluids should be treated with vasopressors, and electrolyte imbalances should be corrected. I.V. immunoglobulin may be considered for severe cases.

Other measures may include supportive treatment for diarrhea, nausea, and vomiting.

Prevention

Menstrual TSS can be prevented by avoiding the use of highly absorbent tampons. Risk can also be reduced by using less absorbent tampons, and by using tampons only intermittently during menstruation.

The best defense against STSS is to clean and bandage all skin wounds as quickly as possible. Call your doctor immediately whenever a wound becomes red, swollen, or tender, or if a fever begins. Although STSS almost never follows strep throat, it's wise to check with your doctor whenever your child has a sore throat with fever, particularly if your child's condition is worsening despite medical treatment.