toxic shock syndrome

Definition

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness that occurs when poisonous substances (toxins) produced by certain bacteria enter the bloodstream. The toxins cause a type of blood poisoning caused by staphylococcal, or less commonly streptococcal, infections in the lungs, throat, skin or bone, or from injuries. Women using super-absorbent tampons during menstruation were found to be most likely to get toxic shock syndrome.

Description

TSS first came to the attention of the public in the 1970s. Shortly after the introduction of a super-absorbent tampon, young women across the United States experienced an epidemic of serious but unexplained symptoms. Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. The only thing they had in common was that they all were menstruating at the time they felt sick, and all were using tampons—especially super absorbent products.

At its height, the epidemic affected 15,000 people in the United States each year between 1980 and 1984; 15% of the women died. Since the offending products were taken off the market, the numbers of TSS cases have declined sharply. As of 1998, only about 5,000 cases are diagnosed annually in the United States, 5% of which are fatal. The decline is most likely due to the tampon manufacturers' discontinuing the use of some synthetic materials, and the removal from the market of the brand of tampon associated with most cases of TSS. Today, most of these products are made with rayon and cotton.

In spite of TSS' association with menstruating women, the disease can affect anyone of either sex or any age or race. The infection may occur in children, men, and non-menstruating women who are weakened from surgery, injury, or disease, and who cannot fight off a staphylococcal infection. New mothers are also at higher risk for TSS.

Most cases reported in the recent past, however, still involve menstruating women under age 30. TSS still occurs in about 17 out of every 100,000 menstruating girls and women each year; more than half of these cases are related to tampons. Between five and 10% of patients with TSS die.

A new type of toxic shock syndrome is caused by a different bacteria, called Group A streptococcus. This form of TSS is called streptococcal toxic shock syndrome, or STSS. Officially recognized in 1987, STSS is related to the strain of streptococcus nicknamed the "flesh-eating bacterium." STSS affects only one or two out of every 100,000 Americans. It almost never follows a simple "strep throat" infection.

— Carol A. Turkington

A serious, sometimes life-threatening disease usually caused by a toxin produced by some strains of the bacterium Staphylococcus aureus. The signs and symptoms are fever, abnormally low blood pressure, nausea and vomiting, diarrhea, muscle tenderness, and a reddish rash, followed by peeling of the skin.

Toxic shock syndrome was first reported in 1978 in seven pediatric patients. However, in 1980 hundreds of cases were reported among young women without apparent staphylococcal infections. Epidemiologists observed that the illness occurred predominantly in young women who were menstruating and were using tampons, especially those that contained so-called superabsorbent synthetic materials. A toxin [toxic shock syndrome toxin number 1 (TSST-1)] that occurs in some strains of staphylococci was later identified. These bacteria are known to proliferate in the presence of foreign particles in human infections, and it has been postulated that the tampons acted as foreign particles, allowing toxin-producing staphylococci to multiply in the vagina.

Several hundred cases of toxic shock syndrome not associated with menstruation have been reported. In these cases, which occurred in males as well as females, there was almost always an overt staphylococcal infection. Susceptibility may depend on lack of antibodies to the toxin that occur in most adults.

The toxin has been shown to occur in only about 1% of the staphylococcal strains studied. Moreover, there is some evidence that the syndrome may be caused also by other staphylococcal toxins, particularly enterotoxins. Cases of toxic shock syndrome that were caused by streptococci have been reported. A toxin distinct from TSST-1 appears involved. Persons with the symptoms of toxic shock syndrome should receive immediate medical care to reduce the chance of death. See also Staphylococcus; Toxin.

A severe, acute disease caused by infection with strains of Staphylococcus aureus, phage group I, that produce a unique toxin, enterotoxin F. It is most common in menstruating women using high-absorbency tampons but has occurred in infants, children, and men.

Toxic shock syndrome. (Zitelli/Davis, 2002, courtesy Dr. George Pazin)

Definition

Toxic shock syndrome (TSS) is an uncommon but potentially serious illness that occurs when poisonous substances (toxins) produced by certain bacteria enter the bloodstream. The toxins cause a type of blood poisoning caused by staphylococcal, or less commonly streptococcal, infections in the lungs, throat, skin or bone, or from injuries. Women using super-absorbent tampons during menstruation were found to be most likely to get toxic shock syndrome.

Description

TSS first came to the attention of the public in the 1970s. Shortly after the introduction of a super-absorbent tampon, young women across the United States experienced an epidemic of serious but unexplained symptoms. Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. The only thing they had in common was that they all were menstruating at the time they felt sick, and all were using tampons—especially super-absorbent products.

At its height, the epidemic affected 15,000 people in the United States each year between 1980 and 1984; 15% of the women died. Since the offending products were taken off the market, the numbers of TSS cases have declined sharply. As of 1998, only about 5,000 cases are diagnosed annually in the United States, 5% of which are fatal. The decline is most likely due to the tampon manufacturers' discontinuing the use of some synthetic materials, and the removal from the market of the brand of tampon associated with most cases of TSS. As of the early 2000s, most of these products are made with rayon and cotton.

In spite of TSS's association with menstruating women, the disease can affect anyone of either sex or any age or race. The infection may occur in children, men, and non-menstruating women who are weakened from surgery, injury, or disease, and who cannot fight off a staphylococcal infection. New mothers are also at higher risk for TSS, particularly if they had a caesarean section or if they are breastfeeding their infants.

Most cases reported in Western countries still involve menstruating women under age 30. TSS still occurs in about 17 out of every 100,000 menstruating girls and women each year; more than half of these cases are related to tampons. Between 5% and 10% of patients with TSS die.

In the developing countries, however, toxic shock syndrome often affects children. A recent report of staphylococcal TSS from Saudi Arabia concerned a four-month-old infant. Burns appear to increase the risk of TSS in children in all countries.

Streptococcal Toxic Shock Syndrome (STSS)

A new type of toxic shock syndrome is caused by a different bacterium, called Group A streptococcus. This form of TSS is called streptococcal toxic shock syndrome, or STSS. Officially recognized in 1987, STSS is related to the strain of streptococcus called the flesh-eating bacterium. STSS affects only one or two out of every 100,000 Americans. It almost never follows a simple strep throat infection.

In Europe and the United Kingdom, however, the incidence of streptococcal toxic shock syndrome has continued to rise through the 1990s. In one district in the United Kingdom, the annual rate rose from 1.1 cases per million population in 1990 to 9.5 cases per million by 1999. The fatality rate is 64%, even in healthy young adults.

Causes & Symptoms

Transmission

STSS is caused by a strain of Streptococcus pyogenes found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the bloodstream, causing a potentially fatal infection.

While experts know the name of the bacterium, more than 10 years after the 1980s epidemic scientists still do not fully understand the link between TSS and tampons. Most medical researchers today suspect that the absorbent tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body. Oxygen triggers bacterial growth, and the more absorbent the tampon, the more bacteria it can harbor. Some experts believe that the reason TSS is linked to tampons in particular is that bacteria can contaminate and multiply in a tampon. If left in place for a long time—as a woman could do with a super absorbent product—the bacteria have a better chance of multiplying and producing a large amount of toxin. It is also possible that the tampons or the chemicals they contain may irritate the vaginal lining, enabling the toxin to enter the bloodstream.

These type of bacteria are normally present either on hands or in the vagina, and it takes an amount of bacteria only the size of a grain of sand to start an infection. Of the 15% of women who carry Staphylococcus aureus, only about 5% have the strain that produces the TSS toxin.

Symptoms

TSS. TSS begins suddenly, with a high fever of 102°F (38.9°C) or above, vomiting and watery diarrhea, headache, and sunburn-like rash; together with a sore throat and body aches. Blood pressure may plummet a day or two after the first symptoms appear. When the blood pressure drops, a woman may become disoriented or go into shock and her kidneys may fail. After these developments, the skin on her hands and feet may peel.

STSS. STSS can occur after a streptococcal infection in the body, usually from an infected wound or even chickenpox. Typically, within 48-96 hours, the patient's blood pressure drops. There is also fever, dizziness, breathing problems, and a weak, rapid pulse. The area around the wound may swell, the liver and kidneys can fail, and bleeding problems may occur.

Diagnosis

Any woman who is wearing a tampon and begins to experience the symptoms of toxic shock syndrome should remove the tampon right away and seek medical care.

The doctor will probably examine the vagina for signs of inflammation and rule out common sexually transmitted diseases with similar symptoms. A variety of blood tests, tests of vaginal secretions, and a physical examination are needed to identify this condition.

Treatment

Toxic shock syndrome is a life-threatening condition. If it is suspected, emergency medical attention should be sought immediately. Treatment with antibiotic drugs and IV fluids will be necessary.

Goldenseal, calendula, and echinacea can be applied topically. A diet low in sugar, with an increase in the consumption of vegetables and fruit helps to build the immune system. Movement therapies and exercise are also beneficial.

Allopathic Treatment

Tss

In a menstruating woman, the vagina is first cleansed with an antiseptic solution to eliminate some of the bacteria that produce the toxin. TSS is treated with antibiotics, together with other drugs and fluids to lower fever and control blood pressure.

Stss

Antibiotics are used to treat STSS. Surgery may be needed to remove dead skin and muscle.

Expected Results

TSS lasts as long as three weeks, and may have a tendency to recur. About a third of the women who are treated for TSS have it again within six months. In addition, TSS can affect the liver, kidneys, lungs, and other organs, depending on the severity of the infection. Untreated toxic shock syndrome can be fatal.

Prevention

Tss

Women who wear tampons should change them often and use different brands and types of pads and tampons. If a woman really prefers tampons, experts recommend using the lowest possible absorbency product made of cotton and rayon, and wearing it only during the day. In the past, it was difficult to compare absorbency rates for different products. Today, the Food and Drug Administration (FDA) requires standardized absorbency measurements on all tampon boxes. Above all, women should wash their hands before inserting a tampon, and change the tampon every four to six hours.

Anyone who has had TSS even once should not use tampons again.

Stss

Doctors still are not sure how people can avoid STSS, but they advise patients to clean and bandage open wounds immediately. Anyone with a red, swollen, or tender wound, or a sudden fever should seek medical care.

Resources

Books

Turkington, Carol A. Infectious Disease A to Z. New York: Facts on File, 1998.

Periodicals

Amir, L. "Breastfeeding and Staphylococcus aureus: Three Case Reports." Breastfeeding Review 10 (March 2002): 15-18.

Barnham, M. R., N. C. Weightman, A. W. Anderson, and A. Tanna. "Streptococcal Toxic Shock Syndrome: A Description of 14 Cases from North Yorkshire, UK." Clinical Microbiology and Infection 8 (March 2002): 174-178.

Ghazal, S. S., M. N. Al-Hawasi, S. A. Al-Mosallam, et al. "Staphylococcal Toxic Shock Syndrome in a Small Infant." Saudi Medical Journal 23 (February 2002): 229-231.

Johnson, D., and P. D. Panthirana. "Toxic Shock Syndrome Following Cessation of Prophylactic Antibiotics in a Child with a 2% Scald." Burns 28 (March 2002): 181-184.

"Toxic shock syndrome—United States." Morbidity and Mortality Weekly Report 46 (22) (June 6, 1997): 492-495.

[Article by: Paula Ford-Martin; Rebecca J. Frey, PhD]

Definition

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness that occurs when poisonous substances (toxins) produced by bacteria enter the bloodstream. The toxins cause a type of blood poisoning that results in high fever, symptoms of shock, and potentially organ failure.

Description

Initially toxic shock syndrome was associated with the use of ultra-absorbent tampons by menstruating girls and women. Between 1978 and 1980 thousands went to emergency rooms with high fever, vomiting, low blood pressure, diarrhea, and a rash resembling sunburn. Once ultra-absorbent tampons were taken off the market, the number of cases of toxic shock syndrome decreased substantially.

As of 2004, two different causes of toxic shock were recognized. Staphylococcal toxic shock syndrome (TSS) is caused by the bacteria Staphylococcus aureus. Streptococcal toxic shock syndrome (STSS, first described in 1987, is caused by Streptococcus pyogenes bacteria. Although both types of toxic shock are rare, STSS is more common and has a higher rate of serious complications and death.

Transmission

TSS is caused by a strain of S. aureus found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the bloodstream, causing a potentially fatal reaction.

Although scientists still do not fully understand the link between TSS and tampons, most medical researchers suspect that tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body. Oxygen triggers bacterial growth, and the more absorbent the tampon, the longer it is left in place and the more toxin-producing bacteria it can harbor.

The streptococcal bacteria that cause STSS often enter the body through an infected wound in the skin, infection following surgery, postpartum or post abortion infection, or bone infection. STSS almost never develops following a simple strep throat infection.

Demographics

Although the majority of cases of TSS occur in menstruating girls and women, the disease may occur in people of any race and age, including children. STSS infection may occur in individuals who are weakened from surgery, injury, or disease that weakens the immune system. New mothers also are at higher risk for toxic shock syndrome, as are those who have recently had chicken pox. This disease is rare. Only about 100 cases of TSS and 300 cases of STSS were reported in the United States in 1996.

Causes and Symptoms

Toxic shock syndrome begins suddenly about two days after infection occurs with a fever of 102°(38.9°C) or above, vomiting and watery diarrhea, headache, and sunburn-like rash, together with a sore throat and body aches. Blood pressure may plummet a day or two after the first symptoms appear. When blood pressure drops, an individual may become disoriented or go into shock. The kidneys or liver may fail. After these developments, the skin on the hands and feet may peel. With STSS, flesh around the infected site may become damaged and die (become necrotic).

When to Call the Doctor

Toxic shock is a medical emergency that needs to be treated immediately in the hospital. Parents should go to the emergency room or call an ambulance if their child has a fast, weak pulse; cold hands and feet with pale moist skin; mental confusion or lethargy; abnormal breathing; a sunburn-like rash; high fever; or skin that is red, swollen, and infected.

Diagnosis

Diagnosis is made based on history, presenting symptoms, and culture of bacteria from the blood or wound. A rapid streptococcal test can be done with results available in 15 minutes. This test is positive in more than 85 percent of cases of toxic shock.

Treatment

Because toxic shock is a medical emergency, treatment is usually begun before laboratory results are available. The first line of treatment is to attempt to reverse the symptoms of shock. This process usually involves the administration of fluids intravenously. The site of infection is cleaned, and antibiotics are administered. If organ failure occurs, oxygen, the use of a respirator, or kidney dialysis may be necessary. It may also be necessary to surgically remove any infected and dying tissue.

Prognosis

Many otherwise healthy individuals recover from toxic shock in two to three weeks; however, the length of recovery is variable and depends on how early and how aggressively the disease is treated. About 3 percent of individuals with TSS die. The death rate with STSS can be as high as 30 to 70 percent.

Prevention

Women and girls who use tampons should always wash their hands before inserting a tampon and change the tampon every four to six hours. Skin wounds should be cleaned with an antiseptic and covered with a bandage.

Parental Concerns

Although the risk of TSS is very low, parents may prefer that their daughters use pads rather than tampons when menstruating.

Resources

Books

Marx, John. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby, 2002.

Periodicals

"A Quick Diagnosis of Toxic Shock Syndrome Is Critical for Avoiding Mortality." Health & Medicine Week (December 1, 2003): 616.

Web Sites

Sharma, Sat, and Godfrey Harding. "Toxic Shock Syndrome." eMedicine Medical Library, January 22, 2003. Available online at www.emedicine.com/med/topic2292.htm (accessed October 4, 2004).

[Article by: Tish Davidson, A.M.]

For more information on toxic shock syndrome, visit Britannica.com.

Toxic Shock Syndrome (TSS), a rare, sometimes fatal disease that caused widespread panic among women during the early 1980s when the Centers for Disease Control (CDC) and other public health organizations linked the growing number of cases of TSS with the increasing popularity of high-absorbency tampons. The earliest reported cases of TSS occurred among seven children in 1978 and were linked with the presence of Staphylococcus aureus. Symptoms of the disease include vomiting, diarrhea, high fever, and sunburnlike rash. Fatalities among early TSS patients were around 8 percent. In 1980,890 cases were reported to the CDC, 812 of which were among women whose illness coincided with the start of their menstrual periods. When the Utah Department of Health collected information suggesting that women with TSS had used a particular tampon brand, Rely, the CDC devised a study to examine tampon brand use. The study found that 71 percent of a test group of women with TSS had used Rely tampons. On 22 September 1980, Procter and Gamble recalled all Rely tampons on the market and all tampon manufacturers subsequently lowered the absorbency of their tampons. The Food and Drug Administration began requiring that all tampon packages carry information on TSS, advising women to use tampons with the minimum absorbency needed and to change tampons frequently. Though the scare associated menstruating women with TSS, the disease has been reported in men, children, and older women and in conjunction with surgery, influenza, sinusitis, childbirth, intravenous druguse, cuts, boils, abscesses, insect bites, and the use of contraceptive sponges, cervical caps, and diaphragms.

Bibliography

Donawa, Maria E. et al. "Toxic Shock Syndrome: Chronology of State and Federal Epidemiologic Studies and Regulatory Decision-Making." Public Health Reports 99 (1984).

Etheridge, Elizabeth W. Sentinel for Health: A History of the Centers for Disease Control. Berkeley: University of California Press, 1992.

Sapolsky, Harvey M., ed. Consuming Fears: The Politics of Product Risks. New York: Basic Books, 1986.

Toxic shock syndrome
Classification and external resources
ICD-10	A48.3
ICD-9	040.82
DiseasesDB	13187
eMedicine	med/2292 emerg/600 derm/425 ped/2269
MeSH	D012772

Toxic shock syndrome (TSS) is a very rare but potentially fatal illness caused by a bacterial toxin. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative bacteria include Staphylococcus aureus and Streptococcus pyogenes. Streptococcal TSS is sometimes referred to as toxic shock-like syndrome (TSLS) or Streptococcal Toxic Shock Syndrome (STSS).

Contents 1 Routes of infection 2 Incidence 3 History 3.1 Initial description of toxic shock syndrome 3.2 Rely tampons 4 Symptoms and diagnosis 5 Pathogenesis 6 Treatment and prognosis 7 See also 8 References 9 External links

Routes of infection

TSS can occur via the skin (e.g., cuts, surgery, burns), vagina (prolonged tampon exposure), or pharynx. However, most of the large number of individuals who are exposed to or colonized with toxin-producing strains of S. aureus or S. pyogenes do not develop toxic shock syndrome. One reason is that a large percentage of the population have protective antibodies against the toxins that cause TSS.^[1] It is not clear why the antibodies are present in people who have never had the disease, but likely that given these bacteria's pervasiveness and presence in normal flora, minor cuts and such allow natural immunization on a small scale.

It is believed that approximately half the cases of staphylococcal TSS reported today are associated with tampon use during menstruation. However, TSS can also occur in children, men, and non-menstruating women.

Although scientists have recognized an association between TSS and tampon use, no firm causal link has been established. Research conducted by the CDC suggested that use of some high-absorbency tampons increased the risk of TSS in menstruating women. A few specific tampon designs and high-absorbency tampon materials were found to have some association with increased risk of TSS. These products and materials are no longer used in tampons sold in the U.S. (The materials include polyester, carboxymethylcellulose and polyacrylate).^[2] Tampons made with rayon do not appear to have a higher risk of TSS than cotton tampons of similar absorbency.^[3]

Toxin production by S. aureus requires a protein-rich environment, which is provided by the flow of menstrual blood, a neutral vaginal pH, which occurs during menstruation, and elevated oxygen levels, which are provided by the tampon that is inserted into the normally anaerobic vaginal environment.^[4] Although ulcerations have been reported in women using super-absorbent tampons, the link to menstrual TSS, if any, is unclear. The toxin implicated in menstrual TSS is capable of entering the bloodstream by crossing the vaginal wall in the absence of ulcerations.^[5] Women can avoid the risk of contracting TSS by choosing a tampon with the minimum absorbency needed to manage their menstrual flow and using tampons only during active menstruation. Alternately, a woman may choose to use a different kind of menstrual product that may eliminate or reduce the risk of TSS, such as a menstrual cup or sanitary napkin.

Incidence

Staphylococcal toxic shock syndrome is rare and the number of reported cases has declined significantly since the 1980s. Patrick Schlievert, who published a study on it in 2004, determined its incidence at 3 to 4 out of 100,000 tampon-using females per year; the information supplied by manufacturers of sanitary products such as Tampax and Stayfree puts it at 1 to 17 of every 100,000 menstruating females per year.^[6][7] The CDC has stopped tracking TSS. However, there was a rise in reported cases in the early 2000s: eight deaths from the syndrome in California in 2002 after three successive years of four deaths per year, and Schlievert's study found that cases in part of Minnesota more than tripled from 2000 to 2003.^[6] Schlievert considers earlier onset of menstruation to be a cause of the rise; others, such as Philip M. Tierno, blame new high-absorbency tampons introduced in 1999 and manufacturers discontinuing warnings not to leave tampons in overnight.^[6]

History

Initial description of toxic shock syndrome

The term toxic shock syndrome was first used in 1978 by a Denver pediatrician, Dr. James K. Todd, to describe the staphylococcal illness in three boys and four girls aged 8-17 years.^[8] Even though S. aureus was isolated from mucosal sites in the patients, bacteria could not be isolated from the blood, cerebrospinal fluid, or urine, raising suspicion that a toxin was involved. The authors of the study noted that reports of similar staphylococcal illnesses had appeared occasionally as far back as 1927. But the authors at the time failed to consider the possibility of a connection between toxic shock syndrome and tampon use, as three of the girls who were menstruating when the illness developed were using tampons. Many cases of TSS occurred after tampons were either left in or lost inside the woman. ^[9]

Rely tampons

Package of Rely Tampons

Following a controversial period of test marketing in Rochester, New York and Fort Wayne, Indiana,^[10] in August 1978 Procter and Gamble introduced superabsorbent Rely tampons to the United States market^[11] in response to women's demands for tampons that could contain an entire menstrual flow without leaking or replacement.^[2] Rely used carboxymethylcellulose (CMC) and compressed beads of polyester for absorption. This tampon design could absorb nearly 20 times its own weight in fluid.^[12] Further, the tampon would "blossom" into a cup shape in the vagina in order to hold menstrual fluids without leakage.

In January 1980, epidemiologists in Wisconsin and Minnesota reported the appearance of TSS, mostly in menstruating women, to the CDC.^[13] S. aureus was successfully cultured from most of the women. A CDC task force investigated the epidemic as the number of reported cases rose throughout the summer of 1980, accompanied by widespread publicity. In September 1980, the CDC reported that users of Rely were at increased risk for developing TSS.^[14]

On September 22, 1980, Procter and Gamble recalled Rely^[15] following release of the CDC report. As part of the voluntary recall, Procter and Gamble entered into a consent agreement with the FDA "providing for a program for notification to consumers and retrieval of the product from the market."^[16] However, it was clear to other investigators that Rely was not the only culprit. Other regions of the United States saw increases in menstrual TSS before Rely was introduced.^[17] It was shown later that higher absorbency of tampons was associated with an increased risk for TSS, regardless of the chemical composition or the brand of the tampon. The sole exception was Rely, for which the risk for TSS was still higher when corrected for its absorbency.^[18] The ability of carboxymethylcellulose to filter the S. aureus toxin that causes TSS may account for the increased risk associated with Rely.^[12]

By the end of 1980, the number of TSS cases reported to the CDC began to decline. The reduced incidence was attributed not only to the removal of Rely from the market, but also to reduced use of all tampon brands. According to the Boston Women's Health Book Collective, 942 women were diagnosed with tampon-related TSS in the USA from March 1980 to March 1981, 40 of whom died.

Symptoms and diagnosis

Symptoms of toxic shock syndrome vary depending on the underlying cause. TSS resulting from infection with the bacteria Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress to stupor, coma, and multi-organ failure. The characteristic rash, often seen early in the course of illness, resembles a sunburn, and can involve any region of the body, including the lips, mouth, eyes, palms and soles. In patients who survive the initial onslaught of the infection, the rash desquamates, or peels off, after 10–14 days.

In contrast, TSS caused by the bacteria Streptococcus pyogenes, or TSLS, typically presents in people with pre-existing skin infections with the bacteria. These individuals often experience severe pain at the site of the skin infection, followed by rapid progression of symptoms as described above for TSS. In contrast to TSS caused by Staphylococcus, Streptococcal TSS less often involves a sunburn rash.

In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections.^[19]:

1. Body temperature > 38.9 °C (102.02 °F)
2. Systolic blood pressure < 90 mmHg
3. Diffuse rash, intense erythroderma, blanching ("boiled lobster") with subsequent desquamation, especially of the palms and soles
4. Involvement of three or more organ systems:
   • Gastrointestinal (vomiting, diarrhea)
   • Mucous membrane hyperemia (vaginal, oral, conjunctival)
   • Renal failure (serum creatinine > 2x normal)
   • Hepatic inflammation (AST, ALT > 2x normal)
   • Thrombocytopenia (platelet count < 100,000 / mm³)
   • CNS involvement (confusion without any focal neurological findings)

Pathogenesis

In both TSS (caused by S. aureus) and TSLS (caused by S. pyogenes), disease progression stems from a superantigen toxin that allows the non-specific binding of MHC II with T cell receptors, resulting in polyclonal T cell activation. In typical T cell recognition, an antigen is taken up by an antigen-presenting cell, processed, expressed on the cell surface in complex with class II major histocompatibility complex (MHC) in a groove formed by the alpha and beta chains of class II MHC, and recognized by an antigen-specific T cell receptor. By contrast, superantigens do not require processing by antigen-presenting cells but instead interact directly with the invariant region of the class II MHC molecule. In patients with TSS, up to 20% of the body's T cells can be activated at one time. This polyclonal T-cell population causes a cytokine storm, followed by a multisystem disease. The toxin in S. aureus infections is Toxic Shock Syndrome Toxin-1, or TSST-1.

Treatment and prognosis

The severity of this disease frequently warrants hospitalization. Admission to the intensive care unit is often necessary for supportive care (for aggressive fluid management, ventilation, renal replacement therapy and inotropic support), particularly in the case of multiple organ failure.^[20] The source of infection should be removed or drained if possible: abscesses and collections should be drained. Women wearing a tampon at the onset of symptoms should remove it immediately. Outcomes are poorer in patients who do not have the source of infection removed.^[20]

Antibiotic treatment should cover both S. pyogenes and S. aureus: this may include a combination of cephalosporins, penicillins or vancomycin. The addition of clindamycin^[21] or gentamicin^[22] reduces toxin production and reduces mortality.

With proper treatment, patients usually recover in two to three weeks. The condition can, however, be fatal within hours.

See also

• Necrotizing fasciitis
• Septic shock
• Toxic headache

References

1. ^ McCormick J, Yarwood J, Schlievert P (2001). "Toxic shock syndrome and bacterial superantigens: an update". Annu Rev Microbiol 55: 77–104. doi:10.1146/annurev.micro.55.1.77. PMID 11544350. 
2. ^ ^{a b} Citrinbaum, Joanna (Oct. 14, 2003). "The question's absorbing: 'Are tampons little white lies?'". The Digital Collegian. http://www.collegian.psu.edu/archive/2003/10/10-14-03tdc/10-14-03dscihealth-01.asp. Retrieved 2006-03-20. 
3. ^ Parsonnet J, Modern P, Giacobbe K (1996). "Effect of tampon composition on production of toxic shock syndrome toxin-1 by Staphylococcus aureus in vitro". J Infect Dis 173 (1): 98–103. PMID 8537689. 
4. ^ McCormick J, Yarwood J, Schlievert P (2001). "Toxic shock syndrome and bacterial superantigens: an update". Annu Rev Microbiol 55: 77–104. doi:10.1146/annurev.micro.55.1.77. PMID 11544350. 
5. ^ Schlievert P, Jablonski L, Roggiani M, Sadler I, Callantine S, Mitchell D, Ohlendorf D, Bohach G (2000). "Pyrogenic toxin superantigen site specificity in toxic shock syndrome and food poisoning in animals". Infect Immun 68 (6): 3630–4. doi:10.1128/IAI.68.6.3630-3634.2000. PMID 10816521. 
6. ^ ^{a b c} Julie Sevrens Lyons/Knight Ridder Newspapers, "A New Generation Faces Toxic Shock Syndrome," The Seattle Times, January 25 2005, http://seattletimes.nwsource.com/html/health/2002160362_healthtoxicshock26.html, accessed April 8 2009, first published as "Lingering Risk," San Jose Mercury News, December 13 2004
7. ^ "Stayfree - FAQ About Toxic Shock Syndrome (TSS)". 2006. http://www.stayfree.com/faq_TSS.jsp. Retrieved 2006-10-13. 
8. ^ Todd J, Fishaut M, Kapral F, Welch T (1978). "Toxic-shock syndrome associated with phage-group-I staphylococci". Lancet 2 (8100): 1116–1118. doi:10.1016/S0140-6736(78)92274-2. PMID 82681. 
9. ^ Todd J (1981). "Toxic shock syndrome--scientific uncertainty and the public media". Pediatrics 67 (6): 921–923. PMID 7232057. 
10. ^ Finley, Harry. "Rely Tampon: It Even Absorbed the Worry!". Museum of Menstruation. http://www.mum.org/Rely.htm. Retrieved 2006-03-20. 
11. ^ Hanrahan S (1994). "Historical review of menstrual toxic shock syndrome". Women Health 21 (2-3): 141–65. doi:10.1300/J013v21n02_09. PMID 8073784. 
12. ^ ^{a b} Vitale, Sidra (1997). "Toxic Shock Syndrome". Web by Women, for Women. http://www.io.com/~wwwomen/menstruation/tss.html. Retrieved 2006-03-20. 
13. ^ CDC 1980. "Toxic-shock syndrome--United States." MMWR 29(20):229-230.
14. ^ CDC 1980. "Follow-up on toxic-shock syndrome." MMWR 29(37):441-445.
15. ^ Hanrahan S (1994). "Historical review of menstrual toxic shock syndrome". Women Health 21 (2-3): 141–165. doi:10.1300/J013v21n02_09. PMID 8073784. 
16. ^ Kohen, Jamie (2001). "The History and Regulation of Menstrual Tampons". RTF document. http://leda.law.harvard.edu/leda/data/359/Kohen.html. Retrieved 2006-03-30. 
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19. ^ Case Definitions for Public Health Surveillance
20. ^ ^{a b} Zimbelman J, Palmer A, Todd J. "Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection". Ped Infect Dis J 18 (12): 1096–1100. http://www.pidj.org/pt/re/pidj/abstract.00006454-199912000-00014.htm;jsessionid=JZ2WwJhpv8J4dh2nDJWTywCFB4Lyy8L6Xw61G1hMCl2jYXBhQGp2!-2118404334!181195629!8091!-1. 
21. ^ Schlievert PM, Kelly JA (1984). "Clindamycin-induced suppression of toxic-shock syndrome-associated exotoxin production". J Infect Dis 149 (3): 471. 
22. ^ van Langevelde P, van Dissel JT, Meurs CJ, Renz J, Groeneveld PH (01 Aug 1997). "Combination of flucloxacillin and gentamicin inhibits toxic shock syndrome toxin 1 production by Staphylococcus aureus in both logarithmic and stationary phases of growth". Antimicrob Agents Chemother 41 (8): 1682–1685. PMID 9257741. http://aac.asm.org/cgi/content/abstract/41/8/1682. 

External links

• Toxic Shock Syndrome and Tampons at the University of Illinois' McKinley Health Center website
• Streptococcal Toxic-Shock Syndrome: Spectrum of Disease, Pathogenesis, and New Concepts in Treatment - a 1995 paper on TSS
• eMedicine Health

For more information on Toxic Shock Syndrome - visit http://www.tssis.com/

v • d • e Infectious diseases · Bacterial diseases: G+ (primarily A00–A79, 001–041, 080–109) Firmicutes/ (low-G+C) Bacilli Lactobacillales (Cat-) Streptococcus Alpha hemolytic optochin susceptible: S. pneumoniae (Pneumococcal infection) optochin resistant: S. viridans (S. mitis, S. mutans, S. oralis, S. sanguinis, S. sobrinus, milleri group) Beta hemolytic A, bacitracin susceptible: S. pyogenes (Scarlet fever, Erysipelas, Rheumatic fever, Streptococcal pharyngitis) B, bacitracin resistant, CAMP test+: S. agalactiae Gamma hemolytic D, BEA+: Streptococcus bovis Enterococcus BEA+: Enterococcus faecalis (Urinary tract infection) · Enterococcus faecium Bacillales (Cat+) Staphylococcus Cg+ S. aureus (Staphylococcal scalded skin syndrome, Toxic shock syndrome, MRSA) Cg- novobiocin susceptible (S. epidermidis) · novobiocin resistant (S. saprophyticus) Bacillus Bacillus anthracis (Anthrax) · Bacillus cereus (Food poisoning) Listeria Listeria monocytogenes (Listeriosis) Clostridia Clostridium (spore-forming) motile: Clostridium difficile (Pseudomembranous colitis) · Clostridium botulinum (Botulism) · Clostridium tetani (Tetanus) nonmotile: Clostridium perfringens (Gas gangrene, Clostridial necrotizing enteritis) Peptostreptococcus (non-spore forming) Peptostreptococcus magnus Mollicutes Mycoplasmataceae Ureaplasma urealyticum (Ureaplasma infection) · Mycoplasma genitalium · Mycoplasma pneumoniae (Mycoplasma pneumonia) Anaeroplasmatales Erysipelothrix rhusiopathiae (Erysipeloid) Actinobacteria/ (high-G+C) Actinomycineae Actinomycetaceae Actinomyces israelii (Actinomycosis) · Tropheryma whipplei (Whipple's disease) Propionibacteriaceae Propionibacterium acnes Corynebacterineae Mycobacteriaceae M. tuberculosis/M. bovis Tuberculosis: Ghon focus/Ghon's complex · Pott disease · brain (Meningitis, Rich focus) · cutaneous (Scrofula, Bazin disease, Lupus vulgaris, Prosector's wart) · Miliary · Tuberculous pericarditis M. leprae Leprosy Nontuberculous R1: M. kansasii · M. marinum R2: M. gordonae R3: M. avium complex (MAA, MAP, MAI, Lady Windermere syndrome) · M. ulcerans (Buruli ulcer) · M. haemophilum R4: M. fortuitum · M. chelonae Nocardiaceae Nocardia asteroides/Nocardia brasiliensis (Nocardiosis) · Rhodococcus equi Corynebacteriaceae Corynebacterium diphtheriae (Diphtheria) · Corynebacterium minutissimum (Erythrasma) · Corynebacterium jeikeium Bifidobacteriaceae Gardnerella vaginalis

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