Toxic Shock Syndrome | HealthLink BC

What is Toxic Shock Syndrome?

Toxic shock syndrome (TSS) is a rare, but serious illness that can often be life-threatening. TSS develops suddenly after certain types of bacteria enter the bloodstream and produce toxins (poisons). It can quickly affect several different organs including your liver, lungs and kidneys. Since TSS develops quickly, emergency medical help is needed as soon as possible.

Although TSS has been linked to tampon and menstrual cup use by menstruating individuals, it can occur in anyone. Only half of the cases of TSS are linked to menstruation.

If you think you have TSS, call 9-1-1 or go to the nearest emergency department right away.

What causes TSS?

TSS is caused by toxins made by some types of bacteria. The 2 bacteria that make toxins that can cause TSS are:

• Staphylococcus aureus (SA) (commonly known as staph)
• Group A Streptococcus (GAS)

For more information on group A Streptococcus, see HealthLinkBC File #106 Group A Streptococcal Infections.

Staphylococcus aureus are found in the nose or on the skin of up to 30 per cent of people. They are also found in the vagina of about 10 to 20 per cent of women. These bacteria are usually not harmful, and only cause mild nose, throat or skin infections.

In some cases, SA infections can result in TSS. SA makes several toxins and when the toxins enter your bloodstream you can have a severe reaction causing TSS. The toxins may enter your bloodstream through a wound to the skin, including a surgical wound. TSS can also occur in menstruating individuals using tampons or a menstrual cup. Most people, however, are not affected by the toxins because they have developed antibodies to them.

What are the symptoms of TSS?

Symptoms of TSS include flu-like symptoms such as fever, headache and muscle soreness. These symptoms will develop quickly and are severe. Other symptoms may include pain at the site of a wound, vomiting and diarrhea, signs of shock including low blood pressure and light-headedness, shortness of breath and a sunburn-like rash.

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

If you experience the above symptoms after using tampons, a menstrual cup or after a surgery or skin injury, contact your health care provider immediately.

What should I do if I think I have TSS?

Toxic shock syndrome requires immediate emergency care in a hospital. Call 9-1-1 or go to the nearest emergency department right away if you think you have TSS.

If you experience any of the symptoms of TSS while using a tampon or menstrual cup, remove the tampon or menstrual cup and see your health care provider right away. Inform them that you were using a tampon or menstrual cup when the symptoms started.

What is the treatment for TSS?

TSS cannot be treated at home. Hospital care is required to treat a staph infection and related complications caused by TSS, such as shock. You will be given antibiotics to kill the bacteria and stop further release of toxins.

If the source of infection involves a tampon, menstrual cup, diaphragm or contraceptive sponge, it should be removed as soon as possible.

Who is at risk of TSS?

TSS from a staph infection can affect anyone; however, some people are at greater risk of TSS than others.

Risk factors for TSS include:

• Past history of SA toxic shock syndrome
• Prolonged use of a tampon, especially the super absorbent type, or menstrual cup
• Use of contraceptive sponges, diaphragms or intrauterine devices
• Irritation and inflammation of the vagina, also known as vaginitis
• A burn, skin infection or injury, including a wound from surgery. Those who develop a SA wound infection after surgery may be at greater risk of TSS
• Recent respiratory infections, such as sinusitis, sore throat (pharyngitis), laryngitis, tonsillitis or pneumonia

Although menstruating individuals using tampons or a menstrual cup are at higher risk of TSS, tampons and menstrual cups do not cause TSS.

Can TSS be prevented?

TSS can be prevented by keeping all burns, wounds, scrapes and animal or insect bites clean.

If you use tampons, menstrual cups, diaphragms, cervical caps or contraceptive sponges, you can prevent TSS by:

• Following the directions on package inserts, including directions on cleaning and replacement
• Washing your hands with soap before inserting or removing a tampon, menstrual cup, diaphragm or contraceptive sponge
• Changing your tampon at least every 8 hours, or using tampons for only part of the day
• Wearing tampons/menstrual cups and sanitary pads at alternate times. For example, use pads at night and tampons during the day
• Using tampons with the lowest absorbency that you need. The risk of TSS is higher with super absorbent tampons
• Not leaving your diaphragm or contraceptive sponge in for more than 12 to 18 hours

Toxic Shock Syndrome (TSS) | Johns Hopkins Medicine

What is toxic shock syndrome?

Toxic shock syndrome (TSS) is a cluster of symptoms that involves many systems of the body. Certain bacterial infections release toxins into the bloodstream, which then spreads the toxins to body organs. This can cause severe damage and illness.

What causes toxic shock syndrome?

The following bacteria commonly cause TSS:

• Staphylococcus aureus
• Streptococcus pyogenes
• Clostridium sordellii

TSS from Staphylococcus infections was identified in the late 1970s and early 1980s when highly absorbent tampons were widely used by menstruating women. Due to changes in how tampons are made, the incidence of tampon-induced TSS has declined.

TSS from streptococcus infections is most commonly seen in children and the elderly. Other people at risk include those with diabetes, weak immune system, chronic lung disease, or heart disease.

• Staphylococcus infections. Staphylococcus aureus (or S. aureus) may normally exist on a person’s body and does not cause infection. Because it’s part of the body’s normal bacteria, most people develop antibodies to prevent infection. S. aureus can be spread by direct contact with infected persons. People who develop TSS usually have not developed antibodies against S. aureus. Therefore, it’s not usually considered a contagious infection. S. aureus infections may also develop from another infection, 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.
• Streptococcus infections. Streptococcus pyogenes (or S. pyogenes) TSS may occur as a secondary infection. Most commonly, this is seen in people who have recently had chickenpox, bacterial cellulitis (infection of the skin and underlying tissue), or who have weak immune systems.
• Clostridium sordellii infections. Clostridium sordellii (or C. sordellii) normally exists in the vagina and does not cause infection. The bacteria may enter the uterus during normal menstruation, childbirth, or gynecological procedures such as abortion. Intravenous drug use can also cause C. sordellii infections.

Who is at risk for toxic shock syndrome?

The following are risk factors for toxic syndrome:

• 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 recent childbirth, miscarriage, or abortion

What are the symptoms of toxic shock syndrome?

Symptoms of TSS involve many systems and may look like other infections. While each person may experience symptoms differently, the following are the most common symptoms of staphylococcal TSS:

• Fever higher than 102°F (38.9°C)
• Chills
• Feeling unwell
• Headache
• Fatigue
• Rash that is red and flat and that covers most of the areas of the body
• Shedding of the skin in large sheets, especially over the palms and soles, 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

The following are the most common symptoms of streptococcal TSS:

• Dangerously low blood pressure
• Shock
• Decreased kidney function
• Bleeding problems
• Bruising due to low blood platelet count
• Rash that is red and flat and that covers most of the areas of the body
• Liver impairment
• Shedding of the skin in large sheets, especially over the palms and soles (this does not always occur)
• Difficulty breathing

The following are the most common symptoms of C. sordellii TSS:

• Nausea and/or vomiting
• Lethargy
• Flu-like symptoms
• Abdominal tenderness
• Generalized swelling from fluid buildup
• High white blood cell and red blood cell count
• No fever
• Low blood pressure
• Very fast heart rate

How is toxic shock syndrome diagnosed?

Ruling out similar illnesses (such as Rocky Mountain spotted fever, among others) is critical in diagnosing TSS. Other diagnostic tests may include:

• Blood cultures. Tests used to find and identify microorganisms.
• Blood tests. Tests to measure blood clotting and bleeding times, cell counts, electrolytes, and liver function, among others.
• Urine tests.
• Lumbar puncture. A procedure involving the insertion of a needle in between the vertebrae of the spine to draw spinal fluid and check for bacteria.

How is toxic shock syndrome treated?

Specific treatment will be determined by your health care provider based on:

• Your age, 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:

• Giving intravenous (through a vein) antibiotics
• Giving intravenous fluid to treat shock and prevent organ damage
• Heart medications in people with very low blood pressure
• Dialysis may be required in people who develop kidney failure
• Giving blood products
• Supplemental oxygen or mechanical ventilation to assist with breathing
• Deep surgical cleaning of an infected wound

What are the complications of toxic shock syndrome?

TSS can result in amputations of fingers, toes, or limbs, or even death.

Can toxic shock syndrome be prevented?

• 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, and sponges can also help prevent TSS.

When should I call my health care provider?

TSS may start like other infections, but it can quickly progress to a seriously life-threatening disease. If a mild illness quickly becomes severe with whole-body symptoms, seek immediate medical attention.

Key Points about Toxic Shock Syndrome

• Toxic shock syndrome describes a cluster of symptoms that involve many systems of the body.
• It can be caused by Staphylococcus aureus, Streptococcus pyogenes, or Clostridium sordellii.
• Early symptoms are similar to other infections but can progress quickly to become life-threatening.
• TSS can be life-threatening and requires immediate medical attention.

Next Steps

Tips to help you get the most from a visit to your health care provider:

• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the names of new medicines, treatments, or tests, and any new instructions your provider gives you.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

Toxic shock syndrome | Blog maternity hospital Leleka | Media Center

What is Toxic Shock Syndrome (TSS)? This is a rare but very dangerous condition. TSS cannot be called a disease, it is an intoxication of the body as a result of an acute bacterial infection. The infection is caused by staphylococci and streptococci. These bacteria can be present in small amounts in the body, usually in the nasopharynx, without affecting vital functions. But when there are factors that contribute to the rapid reproduction of these bacteria, their number rapidly increases, and toxic waste products become deadly. About half of the cases of TSS develop in women during menstruation.

Signs of toxic shock syndrome

The danger of TSS is that its symptoms do not initially differ from an acute respiratory viral infection. It is often confused with allergies and other diseases, and they expect that after some time the problem will disappear by itself. Therefore, at the first suspicions, you need to check what kind of infection we are talking about. The first signs of TSS are:

• high temperature, 39 degrees and above;
• dizziness, weakness;
• nausea, vomiting;
• delirium;
• low blood pressure;
• sometimes – redness of the throat.

TSS may present with a skin rash, sunburn-like redness, and then peeling. This is a sign that points to the real cause of the problems. However, peeling does not appear immediately, and you should not wait for it: every hour of delay creates additional health risks. With an actively developing TSS, the liver and kidneys are very quickly affected, and other vital systems are involved. Therefore, it is important to check as early as possible whether the described signs are a symptom of toxic shock.

Toxic shock syndrome during menstruation

According to statistics, more than half of all victims of TSS are women who used tampons during menstruation. The mechanism of development of the symptom has not yet been reliably studied. Presumably, it develops in women whose vagina already had colonies of dangerous bacteria. It is sometimes possible for bacteria to soak into the tampon along with the pool water. One way or another, once in a nutrient medium – blood and mucous secretions that the tampon absorbs – the bacteria multiply rapidly. The toxins they produce enter the blood through the walls of the vagina, sometimes through the microscopic scratches left by the tampon. The symptoms described above occur.

Other cases of toxic shock syndrome

In cases where TSS is not due to a tampon, it is also caused by ingested staphylococci and streptococci. The infection enters the body through an open wound. This may be a small wound on the surface of the skin, but more often infection with bacteria occurs after surgery, with insufficient or unskilled care. Reproduction of bacteria can occur, for example, in certain areas of tissues during their necrosis.

Treatment of toxic shock syndrome

If the tampon is changed every few hours, TSS does not have time to develop. But if symptoms similar to TSS suddenly appear, the tampon should be removed immediately, and a new one should not be used until the diagnosis is clarified – it is better to use a pad that absorbs discharge from outside the body.

Be sure to change your tampon after using the pool.

If the symptoms of TSS are severe and last for several days, after removing the tampon, call an ambulance and hospitalize the patient. Once the diagnosis is confirmed, the patient will be prescribed a course of antibiotics and other supportive measures.

Toxic shock syndrome. What is Toxic Shock Syndrome?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Toxic shock syndrome is a severe acute multiorgan damage caused by exotoxins of Staphylococcus aureus or pyogenic streptococcus. Manifested by a sudden rise in temperature to 38.9° C or more, a drop in blood pressure, erythematous skin rashes followed by peeling, profuse diarrhea, vomiting, signs of damage to various organs and systems. The diagnosis of TSS is established on the basis of the clinical picture, physical examination data, laboratory, including bacteriological, analyzes. Treatment involves the sanitation of the bacterial focus, the appointment of antibiotics, infusion and symptomatic therapy.

ICD-10

A48.3 Toxic shock syndrome

• Causes of TSS
• Pathogenesis
• Symptoms of TSS
• Complications
• Diagnostics
• Treatment of toxic shock syndrome
• Prognosis and prevention
• Prices for treatment

General

Toxic shock syndrome (TSS) was first diagnosed in 1978 in seven children with staphylococcal infection. Specialists in the field of gynecology encountered it two years later, noting the association of the development of the syndrome in young women with the use of superabsorbent hygienic tampons during menstruation. The vast majority of patients are women aged 17-30 years. Approximately half of them develop the syndrome associated with menstruation. In a quarter of cases of non-menstrual TSS, the disease occurs in the postpartum period in carriers of Staphylococcus aureus, in 75% – as a result of other causes (skin and subcutaneous infection, surgeries with packing, etc.).

toxic shock syndrome

Causes of TSS

Toxic shock syndrome is caused by exotoxin-producing microorganisms that have a systemic effect on various organs and tissues – Staphylococcus aureus (Staphylococcus aureus) and pyogenic β-hemolytic group A streptococcus (Streptococcus pyogenes). In most cases, the disease does not occur at the time of primary infection with bacteria, but against the background of the carriage of infectious pathogens under the influence of the following predisposing factors:

• Use of tampons. The likelihood of developing TSS increases with the use of hygiene products with enhanced absorbent properties and violation of the recommended frequency of their replacement.
• Use of intravaginal contraceptives. The presence of diaphragms, sponges, caps in the vagina creates favorable conditions for the reproduction of microorganisms.
• Violation of the integrity of the mucous membranes. With injuries of the genital organs, the presence in the uterus of the remains of placental tissue, membranes, blood after childbirth and gynecological operations, optimal conditions arise for bacterial contamination and the penetration of microorganisms or their toxins into the blood.

Non-menstrual toxic shock syndrome can complicate surgical procedures in which dressings are used that accumulate blood (surgeries on the nasal cavity using turundas, wound packing, etc.), and traumatic skin injuries. The combination of these factors with viral diseases (chickenpox, influenza), taking immunosuppressive drugs increases the risk of developing toxemia and bacteremia.

Pathogenesis

A key role in the development of toxic shock syndrome is played by mechanical and chemical influences that promote the growth of bacteria and affect tissue permeability. The starting point is the penetration into the blood of significant amounts of specific toxins (TSST) and their interaction with T-lymphocytes. As a result, cytokines are massively released, causing a multi-organ toxic reaction. The vessels expand and the permeability of their walls increases, which leads to the movement of blood plasma and serum proteins into the extravascular space. In this case, a sharp drop in pressure is observed, edema occurs, coagulation is disturbed, and the temperature rises. Under the influence of mediated immune responses and the direct action of toxins, the skin, parenchyma of the liver, lungs and other organs are affected.

Symptoms of TSS

In menstruating women who use tampons, signs of TSS appear on the 3rd to 5th day of menstruation. With toxic shock syndrome, which complicates childbirth or gynecological operations, the pathology manifests itself in the first 2 days of the postpartum or postoperative period. As a rule, the disease occurs acutely. In rare cases, there is a prodrome in the form of general malaise, nausea, headache and muscle pain. The first sign of TSS is severe chills with a temperature rise up to 39-40°C, after which a complete clinical picture unfolds within 1-4 days.

Almost all patients experience muscle weakness and diffuse muscle pain, especially in the muscles of the proximal limbs, abdominals and back. Often worried about pain in the joints. More than 90% of patients report persistent vomiting and profuse watery diarrhea, scanty urine. There is a sore throat, paresthesia, headache, photophobia, dizziness and fainting against the background of a drop in blood pressure. In some cases, coughing, pain when swallowing are disturbing. In the acute stage, lasting from 24 to 48 hours, the patient appears lethargic and disoriented.

A specific manifestation of the syndrome is a skin rash in the form of diffuse redness, which resembles a sunburn and begins to gradually turn pale over the first 3 days. Subsequently, rough peeling of the skin occurs, especially noticeable on the soles and palms. In some women, redness is in the form of spots of various sizes, which are joined by small nodular rashes or pinpoint petechial hemorrhages. Almost a quarter of the sick on the 5-10th day there is severe itching against the background of a spotty-nodular rash. In almost 100% of patients, by the end of the 1st-2nd week, a shallow generalized scaly exfoliation of the skin epithelium with a more pronounced lamellar peeling of the palms, soles, fingers and toes is observed. Half of the patients who underwent TSS by the end of the 2-3rd month noted hair loss and convergence of nails.

In almost 3/4 cases, hyperemia of the conjunctiva, redness of the posterior pharyngeal wall and oral mucosa, crimson-red color of the tongue are detected. Every third menstruating woman with TSS is concerned about soreness and swelling in the area of ​​the labia majora and labia minora. In severe cases of the syndrome, there are signs of toxic damage to the liver, kidneys, respiratory system with transient icterus of the skin, pain in the abdomen, lower back, right hypochondrium, cloudy urine, shortness of breath, etc.

In addition to the clinically pronounced toxic shock syndrome, there is its erased form (with primary manifestation or repeated episode): the patient has a fever, chills, moderate muscle pain, nausea, vomiting, diarrhea, and a sore throat. However, blood pressure does not decrease and the condition resolves without treatment.

Complications

In severe cases of the syndrome, toxic shock is observed, leading to impaired microcirculation and aggravating damage to parenchymal organs. Respiratory failure occurs with shortness of breath and deterioration of blood oxygenation, DIC with thromboembolism and heavy bleeding, heart rhythm is disturbed, as a result of acute tubular necrosis, the kidneys fail. More than 50% of patients with streptococcal TSS develop bacteremia and necrotizing fasciitis. In the long term, temporary loss of nails and hair, neurological disorders (paresthesia, memory disorders, increased fatigue) are possible.

Diagnostics

Taking into account the multiorgan nature of the disease, in order to make a diagnosis, it is necessary to evaluate both local changes in the female organs and signs of violations of other systems. The comprehensive examination includes:

• Gynecological examination. Puffiness and hyperemia of the genital organs are revealed, in some cases – scanty discharge of a purulent nature from the cervical canal. Palpation can be determined by pain in the appendages.
• Physical examination. In 100% of cases, there is an increase in temperature over 38.9°C and a drop in systolic pressure below 90 mm Hg. (usually with an orthostatic decrease of 15 mm Hg).
• General clinical tests. KLA is characterized by leukocytosis with high neutrophilia, shift of the leukocyte formula to the left, thrombocytopenia, anemia, increased ESR. In the general analysis of urine, an abnormal urinary sediment with leached erythrocytes and sterile pyuria is determined.
• Biochemical blood test. With impaired liver function, the level of bilirubin and the activity of transferases increase (it is detected in almost half of the patients), with renal failure, azotemia and creatininemia occur, and with muscle damage, an increased content of CPK. In the coagulogram, prothrombin time and partial thromboplastin time increase, fibrin degradation products are determined. A blood test for electrolytes reveals metabolic acidosis, a decrease in the level of calcium, phosphorus, sodium, potassium.
• Methods for determining the pathogen. To identify an infectious agent, a bacterial smear from the genital organs with an antibiogram and blood cultures are used (indicated for suspected streptococcal TSS). Serological studies make it possible to assess the parameters of the immune system, to exclude infectious diseases with a similar clinical picture.
• Instrumental diagnostics. ECG allows timely detection of cardiac arrhythmias. Fluorography or chest x-ray are recommended to evaluate the condition of the lungs.

TS syndrome is differentiated from sepsis and infectious diseases (measles, scarlet fever, leptospirosis, hepatitis B, Rocky Mountain spotted fever, typhoid fever, meningococcemia, viral exanthems). The patient is consulted by an anesthesiologist-resuscitator, an infectious disease specialist, a cardiologist, a surgeon, a urologist, a dermatologist, a pulmonologist, and a neuropathologist.

Treatment of toxic shock syndrome

When choosing a treatment regimen for toxic shock syndrome, it is important to provide for the impact on the factors that caused the disease, and measures to stabilize the functions of the affected systems. The patient is shown:

• Sanitation of the bacterial focus. First of all, the tampon, diaphragm, cap (if any) are removed and the vagina is washed with a sterile solution. If bacterially contaminated wounds are detected, tissue excision with areas of necrosis is possible.
• Antibiotic therapy. The choice of drug is based on the results of antimicrobial susceptibility tests. Until such data are obtained, empirical therapy is prescribed, taking into account the likely pathogen and its possible antibiotic resistance. The course is up to 10 days.
• Infusion therapy. A key element of treatment is the restoration of intravascular fluid volume and the stabilization of hemodynamic parameters. Depending on the nature of the disorders, the patient is infused with crystalloid solutions, electrolytes, fresh frozen blood plasma, platelet mass, etc.
• Vasopressors. If correction of the volume of intravascular fluid does not allow normalization of blood pressure, drugs with a pressor effect are administered.

With severe organ failure, the patient may be prescribed hemodialysis (with acute renal failure), artificial ventilation of the lungs with positive expiratory pressure (with respiratory distress syndrome). A number of authors note a faster recovery with the appointment of corticosteroids and immunoglobulins.

Prognosis and prevention

In most cases, thanks to the achievements of modern gynecology, timely diagnosis and treatment, patients with staphylococcal TSS recover in 1-2 weeks, while mortality at the present stage is 2.6%. Temperature and blood pressure normalize within 2 days from the moment of hospitalization, and laboratory parameters – on the 7-14th day. The level of erythrocytes is restored after 4-6 weeks. With streptococcal toxic shock, mortality is still high and reaches 50%. For the prevention of TSS, it is important to follow the recommendations for the use of tampons and the protocols for examination before childbirth and gynecological operations for the timely detection of pathogens.

You can share your medical history, what helped you in the treatment of toxic shock syndrome.

Sources

1. self-treatment.