Toxic Shock Syndrome

Toxic shock syndrome (TSS) is a rare but life-threatening complication of bacterial infection or colonization. TSS can affect anyone, male or female. It generally is characterized by high fever with or without chills, a sunburn-like rash, and shock (low blood pressure and/or very high heart rate).

Symptoms usually evolve very quickly and treatment almost always requires hospitalization, intravenous antibiotics, and IV fluids, often with medicines to increase blood pressure.

Of note, TSS can occur in young women who wear tampons, although it is important to note that tampons themselves don't cause TSS and changes in tampon manufacturing have greatly reduced the risk.

TSS is typically caused by one of two types of bacteria: Staphylococcus aureus (commonly called “staph”) and Streptococcus pyogenes (commonly called “strep”). These bacteria are common in our bodies and do not usually cause problems. In rare cases, the bacteria and/or their toxins can enter the bloodstream and can cause TSS.

TSS caused by staphylococcus aureus:

• Can occur after a tampon is left in too long, although manufacturing changes in tampons have reduced the incidence of tampon-induced TSS significantly
• May occur from another infection such as pneumonia, sinusitis, or osteomyelitis (infection in the bone)
• May occur in the setting of a skin or soft-tissue infection from a wound, burn, or surgical cut

TSS caused by streptococcus pyogenes:

• Is most commonly seen in people who have recently had chickenpox, bacterial cellulitis (infection of the skin and underlying tissue), or have recently given birth, had surgery, or suffered a minor cut or wounds
• Can sometimes can present like a severe flu with nausea and high fever and chills with body aches

While symptoms may vary from child to child, the most common symptoms are listed below. It can look like a severe flu. Symptoms overlap between the two types of TSS, but a medical doctor can help distinguish the two infections with blood tests.

For staphylococcal TSS:

• High fever
• Chills
• Malaise (uneasiness and despair)
• Headache
• Fatigue
• A red, flat rash that covers most of the areas of the body
• Low blood pressure
• Vomiting
• Diarrhea
• Muscle pain
• Increased blood flow to mouth, eyes, and vagina, making them appear red
• Decreased urine output and sediment in urine
• Decreased liver function
• Bruising
• Disorientation and confusion
• Eventual sloughing of the skin (especially the palms and soles) one to two weeks after the onset of symptoms

For streptococcal TSS:

• Low blood pressure
• Decreased kidney function
• Bleeding problems
• Bruising
• Red, flat rash that covers large areas of the body
• Decreased liver function
• Decreased urine output and sediment in urine
• Difficulty breathing
• Eventual sloughing of the skin (especially the palms and soles) one to two weeks after the onset of symptoms

There is no one test, but it’s critical to rule out other illness that look like TSS. Diagnostic tests may include:

• Blood cultures
• Blood tests
• Urine tests
• Wound cultures if indicated
• Lumbar puncture (spinal tap)

If you or your child has TSS, hospitalization will likely be needed. Treatment for TSS may include:

• Intravenous (IV) antibiotics
• Intravenous (IV) fluids
• Cardiac medications (if blood pressure is very low)
• Dialysis (for children who develop kidney failure)
• Administration of blood products
• Supplemental oxygen or mechanical ventilation (to assist with breathing)
• Deep surgical cleaning of an infected wound
• Consultation with an infectious diseases specialist

The following may help prevent TSS:

• If you've had TSS before, avoid using tampons, as reinfection is common.
• Clean and take care of any wounds immediately.
• Keep vaginal foreign body items (diaphragms, tampons, sponges) to a minimum

When using tampons:

• Use care when inserting tampons. Wash your hands before inserting or taking out your tampon. Make sure your fingernails are not sharp or jagged (to avoid tearing your skin).
• Change your tampons at least every four to six hours, or more often if necessary.
• Choose the correct tampon absorbency. When your menstrual flow is lighter, use smaller-sized tampons. TSS occurs more often when super-absorbent tampons are used. Don't use these unless your flow is extremely heavy.
• Alternate between pad and tampon use if possible.
• Don't use tampons to absorb anything other than your menstrual flow.