What is toxic shock syndrome (TSS)?
A sudden and potentially life-threatening illness, toxic shock syndrome (TSS) occurs as a result of an infection with staphylococcus aureus bacteria (staph), streptococcus pyogenes (group A streptococcus / GAS) bacteria (the same that results in strep throat) or Clostridium sordellii (C. sordelli). The bacteria results in the production of a toxin (exotoxin), known as TSS toxin-1 (TSST-1). Overgrowth of bacteria in the bloodstream leads to a release of the poisonous toxin in the body, making a TSS infection a potentially fatal condition.
An infection can occur in anyone exposed to the bacteria, but became associated mostly with menstruating women who used superabsorbent tampon products. When a spike in TSS cases was noted during the late 1970s and early 1980s, certain tampon products (containing polyester foam) were pulled from the market. Since then incidences of TSS in menstruating women have declined somewhat. Cotton or rayon fibres used in modern tampons do not appear to promote bacterial growth as much as polyester products.
Children, men and postmenopausal women can also fall ill with this condition through infection following a wound to the skin, a burn, surgery or possibly when using a prosthetic device. Women who use menstrual sponges, cervical caps or diaphragms are also at risk of a TSS infection. Women who have recently given birth are at higher risk of TSS and will need to be aware of any warning signs.
The majority of cases, however, remain menstruating women who typically experience a sharp drop in blood pressure once the toxin releases in the body. The organs (specifically the heart and the lungs), are then deprived of much needed oxygen, resulting in hypotensive shock, and if not treated immediately, this can result in death. As many as a third of all cases of TSS are women under the age of 19. Up to 30% of those who have been treated for the infection may experience a recurrence.
What happens to the body?
Once the toxins released by bacteria begin circulating in the bloodstream, T cells of the immune system are activated. These cells then produce cytokines, chemicals which cause the system to ‘go into shock’, resulting in tissue damage. The TSST-1 toxin is the one seen most often with toxic shock syndrome infections (80%), but others such as those produced by enterococci A, C, D, E and H or GAS bacteria result in the remainder of infection cases.
GAS or group A streptococcus bacteria which contains a filamentous protein, known as M protein makes a bacterial strain more potent, which results in an infection (causing cell damage and inflammation). A strain that lacks this protein is usually less severe (lethal).
The bacteria essentially need an environment conducive to bacterial growth (i.e. where growth happens quickly) and where toxins can be easily released into the bloodstream. This is why menstruating women, in particular, are vulnerable when using tampons. If a tampon which is inserted makes microscopic tears (via fibres which can scratch) in the wall lining of the vagina (especially if used with a light menstrual flow which can cause dryness), tiny blood vessels can be ruptured, allowing bacteria into the bloodstream. Menstrual sponges, cervical caps, diaphragms and tampons should not be left in a woman’s vagina for long periods of time as a result.
Alternate means for infection include bacteria entering the body through a wound (opening in the skin) or a burn either through injury, childbirth or surgery.
Signs and symptoms of toxic shock syndrome
It’s important to spot the signs of TSS quickly as prompt medical treatment will be required. As a condition, it is classified as rare, but any recognisable signs can quickly lead to a life-threatening condition. Once toxins are released into the bloodstream, an infection can affect multiple areas of the body all at once. An infection typically shows signs within 2 days.
The most common signs and symptoms to look out for include:
- A sudden high fever (38.9 degrees Celsius or 102 degrees Fahrenheit)
- Vomiting and nausea
- Muscle aches
- General malaise
- Acute respiratory distress (or failure)
- Low blood pressure (hypotension) and feeling faint
- A red rash (resembling sunburn) that is flat (not raised) and turns white when pressed lightly
- Redness or swelling around the eyes, mouth and / or throat
- Shedding of the skin, particularly the palms of the hands or soles of the feet
Other signs may be noted in the following:
- A decrease in kidney function (or failure)
- Blood clotting problems (platelets)
- Abnormal liver enzyme measurements
- Necrotising fasciitis, gangrene or myositis (damaged or dead soft tissues)
Some common sign groupings may be recognisable according to the type of bacteria causing an infection. These can include:
- Symptoms caused by the staph bacteria: A sudden high fever, headache, fatigue, vomiting, diarrhoea, red rash (flat), redness around the eyes, mouth, throat or vagina, low urine output, skin shedding (usually within 1 to 2 weeks of an infection entering the bloodstream) and bruising.
- Symptoms caused by streptococcus pyogenes: Considerably low blood pressure, a state of shock (lack of blood flow in the body), pain that is sudden and severe, bruising, bleeding, red rash, shedding skin or difficulties with breathing. This can occur as a complication following a bout of chickenpox (varicella) or a skin infection.
- Symptoms caused by Clostridium sordellii (C. sordellii): Symptoms occur as a result of an infection in the uterus and include nausea and vomiting, abdominal pain, swelling, lack of energy and body weakness, a rapid heart rate, a high red and white blood cell count and general flu-like symptoms. A high fever is not a common symptom with this TSS causing bacterial infection.
When to call the doctor
Any and all signs of toxic shock syndrome must be attended to by a medical professional as soon as possible. If any symptoms are noted shortly after an injury, skin infection, surgery, or use of tampons, diaphragms and sponges, immediate medical assistance is necessary.
Diagnosing and treating toxic shock syndrome
How is a diagnosis made?
Diagnostic procedures and treatment to be implemented must happen quickly to prevent severe complications. A doctor will assess a person’s medical history and the nature of symptoms by asking the following types of questions:
- How long ago did symptoms begin?
- Are the symptoms being experienced severe?
- Have you tried to do anything to alleviate symptoms? (i.e. take a painkiller for a headache)
- Have attempts to alleviate symptoms worked or made you feel worse?
- Do you use superabsorbent tampons, or birth control? What do you use for menstruation and contraception? When last were these used?
A doctor will be looking for any potential infection causes in their line of questioning and will also note any medications being taken (or past reactions to those taken) as well. A doctor will then conduct a physical exam to assess the nature of symptoms. Blood pressure will be taken and if very low, and accompanied by other signs of multiorgan problems (kidneys, liver, lungs, skin or blood), a doctor will likely suspect TSS.
The doctor will then wish to have blood and urine samples analysed (in a laboratory) in order to determine the presence of bacteria and also to identify which type it is. For women, a doctor may request a swab of the throat, vagina and cervix to send to the laboratory for analysis. Blood samples will also be analysed to check the function of the liver and kidneys.
If signs of distress affecting multiple organs in the body are evident, a doctor may recommend other testing procedures in order to determine the extent of damage caused. These can include a CT scan (computerised tomography), chest X-ray or lumbar puncture.
Treatment for toxic shock syndrome
Once a doctor determines TSS is the cause of symptoms in a patient, treatment will likely be administered in hospital (usually in the ICU / intensive-care unit). If treatment is administered quickly enough, before severe damage is caused, TSS is curable. Once hospitalised, medical professionals will carefully monitor the patient’s signs and symptoms and whether treatment implemented is working over the course of a few days (sometimes longer).
Treatment for the majority of TSS cases (which may vary from one infection to another) will usually involve two or more of the following types of treatment:
- Intravenous (IV) fluids to alleviate shock and treat dehydration (further preventing more organ damage)
- Intravenous (IV) antibiotics to stop bacterial growth and help rid the body of accumulated toxins
- Immunoglobulin therapy (administered through an IV) which helps to boost the body’s immune system (against infection)
- Cardiac medications to elevate blood pressure
- Surgical cleaning of any infected wounds (removal of non-living tissue from the infection site / draining an infection of fluid or pus) or surgical removal of foreign objects, such as broken sponge pieces which may have triggered an infection
- Mechanical ventilation or oxygen (if necessary)
- Blood products via transfusion, where needed
- Dialysis (in the case of kidney / renal failure)
Once discharged from hospital, antibiotics may be prescribed to be taken for a further 6 to 8 weeks and frequent visits to an infectious diseases specialist may be required to monitor physical condition through physical examinations and blood tests.
Risk factors and complications
What risk factors are associated with toxic shock syndrome?
- A history of using superabsorbent tampons
- Birth control methods, such as a diaphragm or vaginal (contraceptive) sponge
- Injury with a localised infection (skin wound, burn or following childbirth or an abortion)
- Infection following surgical procedures
- Following a viral infection such as the flu or chickenpox (when the immune system is low)
- Individuals at greater risk of contracting group A streptococcus infections are also at higher risk for TSS, such as those with diabetes
Is toxic shock syndrome contagious?
A TSS infection is not capable of being spread from one person to another. Downtime for recovery (away from school or the workplace) is only needed in order to heal symptoms and treat damage to tissues caused by the release of toxins in the bloodstream. It is not necessary for a person with TSS to isolate themselves from others.
The nature of TSS means that toxins can poison the body fairly quickly. This can cause multiple organ damage which can result in any of the following:
- Reduced blood flow to the body (shock)
- Renal failure (kidneys) – signs include body weakness, fatigue, muscle cramps, high blood pressure, swelling (of the ankles and feet), difficulties with urination, nausea, vomiting, chest pain, shortness of breath, sleeping problems, persistent itching and hiccups
- Liver failure – signs include jaundice, abdominal pain, nausea, vomiting, concentration problems, confusion, and sleepiness
- Heart failure – signs include chest pain, coughing, wheezing, heart palpitations, shortness of breath, fatigue, body weakness, concentration difficulties and a loss of appetite
How to prevent toxic shock syndrome
It is possible to significantly reduce the chances of contracting such a serious bacterial infection. Generally, those who are prone to bacterial infections are at higher risk of TSS exposure, especially if it’s been contracted before. Reinfection can occur in those who have had TSS before (it is not possible to develop immunity to bacteria causing TSS).
Ways to minimise risk and thereby potentially prevent TSS include:
- Treat open wounds, especially deep cuts (including surgical incisions), as early as possible and keep them clean and dry (bandaged). Dressings should also be changed frequently as needed.
- Menstruating women should avoid using superabsorbent tampons.
- Menstruating women should take precaution when using tampons, ensuring to change them frequently as needed (and practice good hygiene when doing so). No tampon should be left inserted for longer than 8 hours. Women should also rather use sanitary pads when flow is light to reduce the chances of tears in the wall lining of the vagina. Handwashing is important before putting a tampon in and after taking one out.
- Menstruating women who have had a prior strep, TSS (staph) or other serious bacterial infection should avoid using tampons.
- Precautions, such as frequent changing, should be taken when using diaphragms, cervical caps or vaginal sponges as a form of birth control (women). It is advisable to consult a doctor before using any internal menstrual or contraceptive devices.
- Practice healthy hygiene habits (in general) – daily handwashing can reduce or remove bacteria.
Outlook for toxic shock syndrome
Signs of toxic shock syndrome are considered a medical emergency. The earlier treatment is administered, the better. Once toxins in the bloodstream begin causing multiple organ complications, TSS becomes increasingly life-threatening.
That said, mortality rates are relatively low (approximately 5% to 15%). The more complications develop, the more severe a person’s condition requiring treatment. Early intervention can prevent serious organ related complications, including respiratory failure or coagulation disorders. Most who receive prompt and sufficient treatment will make a full recovery within a few days and up to several weeks.
A small percentage of people may experience persisting symptoms of muscle weakness, concentration difficulties, emotional imbalances or memory loss for a period of time post recovery.
Women who wish to fall pregnant should not have any fertility affected issues, but it is strongly advisable to ensure that a doctor is well aware of a prior infection so that a baby’s delivery can be closely monitored.