toxic shock syndrome

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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.

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.]

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.

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)

• Diseases and Infestations - Toxic Shock Syndrome : rapidly developing toxemia occurring esp. in women using high-absorbency tampons; TSS

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 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 Signs and symptoms 2 Pathophysiology 3 Treatment 4 Prognosis 5 Epidemiology 6 History 6.1 Initial description 6.2 Rely tampons 7 See also 8 References 9 External links

Signs and symptoms

Symptoms of toxic shock syndrome vary depending on the underlying cause. TSS resulting from infection with the bacterium 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 multiple 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 bacterium 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-like rash.

In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections.^[1]:

1. Body temperature > 38.9 °C (102.02 °F)
2. Systolic blood pressure < 90 mmHg
3. Diffuse rash, intense erythroderma, blanching 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 > 2 times normal)
   • Hepatic inflammation (AST, ALT > 2 times normal)
   • Thrombocytopenia (platelet count < 100,000 / mm³)
   • CNS involvement (confusion without any focal neurological findings)

Pathophysiology

In both TSS (caused by S. aureus) and TSLS (caused by S. pyogenes), disease progression stems from a superantigen toxin that allows the nonspecific 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 TSS Toxin-1, or TSST-1. The TSST-1 is secreted as a single polypeptide chain.

The gene encoding toxic shock syndrome toxin is carried by a mobile genetic element of S. aureus in the SaPI family of pathogenicity islands.^[2]

Treatment

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.^[3] The source of infection should be removed or drained if possible: abscesses and collections should be drained. Anyone 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.^[3]

Antibiotic treatment should cover both S. pyogenes and S. aureus. This may include a combination of cephalosporins, penicillins or vancomycin. The addition of clindamycin^[4] or gentamicin^[5] reduces toxin production and mortality.

Prognosis

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

Epidemiology

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 incidence at 3 to 4 out of 100,000 tampon users 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 people 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 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 and Bruce A. Hanna, blame new high-absorbency tampons introduced in 1999 and manufacturers discontinuing warnings not to leave tampons in overnight.^[6]

History

Initial description

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 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 left in the person using them.^[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.^[12] Rely used carboxymethylcellulose (CMC) and compressed beads of polyester for absorption. This tampon design could absorb nearly 20 times its own weight in fluid.^[13] Further, the tampon would "blossom" into a cup shape in the vagina to hold menstrual fluids without leakage.

In January 1980, epidemiologists in Wisconsin and Minnesota reported the appearance of TSS, mostly in those menstruating, to the CDC.^[14] S. aureus was successfully cultured from most of the subjects. The Toxic Shock Syndrome Task Force was created and investigated the epidemic as the number of reported cases rose throughout the summer of 1980.^[15] In September 1980, the CDC reported users of Rely were at increased risk for developing TSS.^[16]

On 22 September 1980, Procter and Gamble recalled Rely^[17] 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."^[18] 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.^[19] 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.^[20] The ability of carboxymethylcellulose to filter the S. aureus toxin that causes TSS may account for the increased risk associated with Rely.^[13]

By the end of 1980, the number of TSS cases reported to the CDC began to decline, however there is some argument as to whether statistics provided by CDC are reliable due to problems with recognition of TSS symptoms by medical staff and the way in which CDC records TSS cases, many estimate that only around a third of all TSS cases reported to the CDC were included in statistics. The reduced incidence was attributed not only to the removal of Rely from the market, but also to reduced use of all tampon brands.

See also

• Necrotizing fasciitis
• Septic shock
• Toxic headache

References

1. ^ Case Definitions for Public Health Surveillance
2. ^ Lindsay, JA; Ruzin, A, Ross, HF, Kurepina, N, Novick, RP (1998 Jul). "The gene for toxic shock toxin is carried by a family of mobile pathogenicity islands in Staphylococcus aureus.". Molecular microbiology 29 (2): 527–43. PMID 9720870. 
3. ^ ^{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. 
4. ^ Schlievert PM, Kelly JA (1984). "Clindamycin-induced suppression of toxic-shock syndrome-associated exotoxin production". J Infect Dis 149 (3): 471. doi:10.1093/infdis/149.3.471. PMID 6715902. 
5. ^ van Langevelde P, van Dissel JT, Meurs CJ, Renz J, Groeneveld PH (1 August 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. PMC 163985. PMID 9257741. http://aac.asm.org/cgi/content/abstract/41/8/1682. 
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; Submission, Haworth Continuing Features (1994). "Historical review of menstrual toxic shock syndrome". Women Health 21 (2-3): 141–65. doi:10.1300/J013v21n02_09. PMID 8073784. 
12. ^ 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. 
13. ^ ^{a b} Vitale, Sidra (1997). "Toxic Shock Syndrome". Web by Women, for Women. Archived from the original on 2006-03-16. http://web.archive.org/web/20060316030919/http://www.io.com/~wwwomen/menstruation/tss.html. Retrieved 2006-03-20. 
14. ^ CDC 1980. "Toxic-shock syndrome--United States." MMWR 29(20):229-230.
15. ^ Dennis Hevesi (September 10, 2011). "Bruce Dan, Who Helped Link Toxic Shock and Tampons, Is Dead at 64". New York Times. http://www.nytimes.com/2011/09/11/health/research/11dan.html?_r=1&src=tp&smid=fb-share. Retrieved 2011-09-12. "Dr. Bruce Dan, who as a leading federal researcher helped establish a link between the life-threatening disease toxic shock syndrome and the use of tampons, prompting a major shift in the way tampons are produced, died Tuesday in Baltimore. He was 64." 
16. ^ CDC 1980. "Follow-up on toxic-shock syndrome." MMWR 29(37):441-445.
17. ^ Hanrahan S; Submission, Haworth Continuing Features (1994). "Historical review of menstrual toxic shock syndrome". Women Health 21 (2-3): 141–165. doi:10.1300/J013v21n02_09. PMID 8073784. 
18. ^ 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. 
19. ^ Petitti D, Reingold A, Chin J (1986). "The incidence of toxic shock syndrome in Northern California. 1972 through 1983". JAMA 255 (3): 368–72. doi:10.1001/jama.255.3.368. PMID 3941516. 
20. ^ Berkley S, Hightower A, Broome C, Reingold A (1987). "The relationship of tampon characteristics to menstrual toxic shock syndrome". JAMA 258 (7): 917–20. doi:10.1001/jama.258.7.917. PMID 3613021. 

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 Firmicutes (low-G+C) Infectious diseases · Bacterial diseases: G+ (primarily A00–A79, 001–041, 080–109) Bacilli Lactobacillales (Cat-) Streptococcus α optochin susceptible: S. pneumoniae (Pneumococcal infection) optochin resistant: S. viridans: S. mitis, S. mutans, S. oralis, S. sanguinis, S. sobrinus, milleri group β A, bacitracin susceptible: S. pyogenes (Scarlet fever, Erysipelas, Rheumatic fever, Streptococcal pharyngitis) B, bacitracin resistant, CAMP test+: S. agalactiae ungrouped: Streptococcus iniae (Cutaneous Streptococcus iniae infection) γ 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) M: BAC bact (clas) gr+f/gr+a(t)/gr-p(c)/gr-o drug(J1p, w, n, m, vacc)

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