An Overview of Toxic Shock Syndrome

A Rare and Serious Complication of Bacterial Infections

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Toxic shock syndrome (TSS) is a rare but potentially fatal complication of infections caused by streptococcus and staphylococcus bacteria. The initial symptoms are fever and rash—these typically have a rapid onset and require immediate medical attention.

While toxic shock syndrome is often associated with tampon use, the condition is not dependent on menstruation, meaning it does not only occur to people who are menstruating. It occurs in men, women, and children of all ages.

Toxic shock syndrome symptoms
Illustration by JR Bee, Verywell

Symptoms

Toxic shock syndrome is a potential complication of streptococcus and staphylococcus infections. The symptoms of toxic shock syndrome develop when bacteria begin to release exotoxins into the body (called toxic shock syndrome toxin 1 or TSST-1).

The immune system mounts a major response to the toxins by releasing a cascade of immune cells called cytokines. While this response (sometimes referred to as a cytokine storm) is meant to overpower the toxins and help prevent the infection from spreading, it actually overwhelms the entire body and causes a person to go into shock.

There are several signs and symptoms of TSS. The symptoms also depend on the type of bacteria responsible for the infection. A person may also experience specific symptoms related to the preexisting or underlying condition that has led to the case of TSS, such as pneumonia or bone infections (osteomyelitis).

Symptoms of toxic shock syndrome usually come on suddenly and include:

  • high fever (102 degrees Fahrenheit).
  • a rash that looks like a sunburn, especially on the hands and bottom of the feet.
  • low blood pressure (hypotension).
  • fainting.
  • irritated, inflamed, reddened eyes.
  • racing heart (tachycardia).
  • confusion or disorientation.
  • headache.
  • trouble breathing (dyspnea) or fast breathing, which may be signs of adult respiratory distress syndrome (ARDS).
  • seizures.
  • gastrointestinal upset (nausea, vomiting, diarrhea).
  • weakness, fatigue, muscle pain, chills, sore throat, or other flu-like symptoms.

Toxic shock syndrome due to streptococcal bacteria does not always include the rash that is seen with infections caused by staphylococcal bacteria. Infections from staphylococcal bacteria are more commonly associated with tampon use, whereas toxic shock syndrome caused by streptococcal bacteria is often linked to skin infections.

When a person develops TSS as the result of an injury or after having surgery, there may be signs of infection visible at the sight of the wound. This can include pain, redness, swelling, and a purulent discharge (pus).

Toxic shock syndrome is a life-threatening infection and requires immediate medical attention. Left untreated, it can lead to shock, coma, permanent organ damage, and death.

While the symptoms of toxic shock syndrome can also occur in less serious conditions, there are some situations that can make a person more at risk for developing the infections that cause it. A person may have TSS if these symptoms have come on suddenly, progressing rapidly, and if the person is experiencing one of the following:

  • menstruating and using tampons or other internal menstrual products.
  • using birth control products that are inserted into the vagina, such as diaphragms.
  • recovering from surgery or a medical procedure, especially ones that require "packing" such as rhinoplasty (this is when gauze or cotton is packed inside of the nasal cavity).
  • has given birth, miscarried, or had an abortion.
  • has an open wound, injury, or insect bite.
  • sick with a viral infection, like the chicken pox or the flu.

It is important to note that a person who has had toxic shock syndrome before is at an increased risk for getting it again.

Causes

Once inside the body, streptococcal and staphylococcal bacteria begin to produce exotoxins. As toxins are released into the body, the immune system's normal response would be to fight against these exotoxins. However, the toxins released by streptococcal and staphylococcal bacteria cause the immune system to overreact.

The inflammatory response that occurs throughout the whole body is sometimes called a cytokine storm due to the overwhelming release of different types of white blood cells (which produce inflammatory cytokines) into the body to fight infections.

The overactivation of the body's immune response leads to the symptoms of toxic shock syndrome. Left untreated, the response overwhelms the body to the extent that multi-system organ failure, and even death, occurs.

Toxic shock syndrome has often been linked to tampon use in people who are menstruating, but the first cases of the condition described in the 1970s occurred in children. Today, while the majority of toxic shock syndrome cases develop in women, about half occur in people who are not menstruating (nonmenstrual TSS). In fact, approximately 25 percent of cases that are not linked to menstruation develop in men.

The influx of TSS cases that occurred in menstruating women was linked to a specific type of super-absorbent tampon which has since been taken off the market.

Tampon use does not cause toxic shock syndrome. However, using tampons (especially if not changing them for prolonged periods) is an identified risk factor for developing a staphylococcal infection that could lead to TSS.

Streptococcal infections that can result in toxic shock syndrome often occur in people who are otherwise healthy, but who are recovering from a medical procedure, injury, or viral illness. A person who develops streptococcal TSS is also at a higher risk of serious complications, such as necrotizing fasciitis or acute respiratory distress syndrome.

Diagnosis

Men, women, and children of all ages can develop toxic shock syndrome. It occurs most often in people who live in developed countries. In the United States, toxic shock syndrome caused by streptococcal bacteria occurs in about 3 per 100,000 people every year. Cases caused by staphylococcal bacteria are less common, occurring in about 0.5 per 100,000 people each year.

While it's rare, the condition can be life-threatening—even in people who were previously healthy. Therefore, prompt diagnosis and treatment is critical.

The initial symptoms a person has will depend on the bacteria causing the infection. In general, if a person has a high fever and rash that came on quickly and this person also recently gave birth, had surgery, or used tampons, a medical professional will want to determine quickly if toxic shock syndrome is the cause of the symptoms.

CDC Criteria

To help medical professionals make a timely diagnosis and start appropriate treatment, the Centers for Disease Control and Prevention (CDC) set diagnostic criteria for confirming cases of toxic shock syndrome caused by staphylococcal bacteria.

The CDC set the following five criteria to help diagnose toxic shock syndrome:

  1. fever (102.02 °F or 38.9 °C).
  2. hypotension (systolic blood pressure reading of < 90 mmHg).
  3. characteristic, "sunburn-like" rash on palms of hands or bottom of feet.
  4. skin peeling (desquamation) one to two weeks after the rash starts.
  5. involvement of three or more organ systems including GI, musculoskeletal, cardiovascular, urinary and kidney, liver, blood, mucosal, and nervous system.

In addition to the above criteria, a person must also test negative for several other conditions that can cause similar symptoms. Blood tests and cultures of body fluids must test negative for other bacteria and infections (measles and tick-borne illness, for instance).

Tests

As toxic shock syndrome is a result of the body's overreactive immune response to an infection, there is no specific test for the condition. Instead, an assessment will be made of a patient's clinical symptoms and risk factors. Several tests will be performed to confirm the presence of infection as well as to identify whether it is due to streptococcal or staphylococcal bacteria.

Tests that a medical professional may order if toxic shock syndrome is suspected include:

  • blood tests to assess the activity of the immune system (such as looking at the number of white blood cells).
  • tests to evaluate the function of specific body systems that may be affected, such as the liver, kidneys, or central nervous system.
  • cultures to look for streptococcal or staphylococcal bacteria.
  • imaging tests like an MRI or CT can be used to see if wounds (such as a surgical site) are infected in the soft tissue.
  • specific tests or cultures to rule out other conditions and infections that can have similar symptoms (Reye syndrome, gangrene, measles).

Multiple blood tests and types of cultures may need to be done to determine the source and cause of the infection. For example, a person's blood test may be negative for streptococcal bacteria, but a culture taken from a skin wound may be positive for staphylococcal bacteria.

Even if a case of TSS is deemed "probable" (meaning it meets all but one diagnostic criterion), but is not yet "confirmed" according to CDC criteria, medical intervention will be needed to prevent potentially life-threatening complications.

A person who has a probable or confirmed case of toxic shock syndrome needs immediate and often intensive medical monitoring and treatment.

Most often they will need to be admitted to the hospital and may spend time in the intensive care unit (ICU).

Treatment

While toxic shock syndrome is uncommon, accurately and timely diagnosis, as well as prompt treatment, is very important—it can take anywhere between a couple of hours and a couple of days for the condition to turn life-threatening. Most people with the condition will need to be admitted to the hospital for intensive treatment and medical monitoring.

Medical professionals will need to determine the cause and source of the infection that leads to the development of toxic shock syndrome to assure proper treatment. If it is determined that the infection is something that can be removed (like a tampon) the first intervention is to remove the source.

Broad-spectrum antibiotics, which may need to be given intravenously, are the standard treatment for toxic shock syndrome.

Antibiotics Used to Treat TSS

However, the exact medications used will depend on the bacteria that is causing the infection and the location of the infection. For example, drugs such as oritavancin (Orbactiv) have been specifically approved by the FDA to treat bacterial infections in skin wounds.

Some bacteria have grown resistant to antibiotics, so multiple medications may be needed to adequately treat the infection and prevent complications from toxic shock syndrome. People will usually need the standard course of therapy, which is seven to 14 days. Longer treatment or additional treatment may be needed depending on the severity of the infection and whether complications arise.

While they are being treated for the underlying infection, a person hospitalized with TSS may also receive supportive measures to help with symptoms such as pain and dehydration. These interventions may include:

  • IV fluids and electrolyte replenishment.
  • medications to help with pain and discomfort.
  • antiemetics to help control nausea and vomiting.
  • treatment of any wounds that are present (such as debridement or cleaning).

Patients are also at risk for going into shock, particularly while they are receiving IV fluids during treatment. Therefore, medical professionals may also prescribe certain drugs to help control blood pressure (vasopressors).

Once a person has had toxic shock syndrome, they are at risk for developing it again. Therefore, people who were menstruating and using tampons, menstrual cups, or other devices inserted into the vagina when they developed the condition will be advised to avoid using these products.

There is no vaccine or specific treatment that will prevent toxic shock syndrome. The best course of prevention is to avoid known risks for developing the condition. Useful tips to avoid TSS include:

  • menstruating people are advised to frequently change tampons and not use super-absorbent varieties.
  • keep devices inserted into the vagina clean (such as cervical caps, diaphragms, and birth control rings).
  • practicing proper hygiene and wound care after surgery or medical procedures.
  • being aware of the potential signs and symptoms of TSS when recovering from childbirth, miscarriage, or abortion procedures
  • awareness and timely treatment of post-infectious complications in children that can occur after illnesses like chicken pox.

With proper diagnosis and treatment, most people will recover from toxic shock syndrome in a few weeks. However, if the condition is not diagnosed and treated quickly, toxic shock syndrome can be fatal in just a couple of days. Cases of toxic shock syndrome caused by streptococcal bacteria can have a fatality rate of over 50 percent.

A Word From Verywell

Toxic shock syndrome is a rare but potentially fatal complication of infections. The initial symptoms of fever and rash typically have a rapid onset and require immediate medical attention, including intravenous antibiotics and hospitalization in the ICU. The condition is not menstruation dependent and occurs in men, women, and children of all ages. Once a person has had TSS, they are at risk for developing it again. While there is no specific vaccine or treatment that prevents the condition, people can reduce the likelihood of getting the infection by avoiding known risk factors and by being aware of the signs and symptoms so that you can seek immediate medical treatment if necessary.

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