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, which typically have a rapid onset and require immediate medical attention.

While toxic shock syndrome is often associated with tampon use, tampons are not the only cause. The condition also affects people who are not menstruating, including people of all genders and ages.

This article explains TSS symptoms, causes, diagnosis, and treatment.

Toxic shock syndrome symptoms
Illustration by JR Bee, Verywell

Symptoms

There are several signs and symptoms of TSS. The symptoms also depend on the type of bacteria responsible for the infection.

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
  • Hypotension (low blood pressure)
  • Fainting
  • Irritated, inflamed, reddened eyes
  • Tachycardia (racing heart)
  • Confusion or disorientation
  • Headache
  • Dyspnea (trouble breathing)
  • Fast breathing, which may be a sign of adult respiratory distress syndrome (ARDS)
  • Seizures
  • Gastrointestinal upset (nausea, vomiting, diarrhea)
  • Weakness, fatigue, muscle pain, chills, sore throat, or other flu-like symptoms

When you develop TSS due to an injury or after having surgery, you may have additional infection symptoms, including pain, redness, swelling, and discharge (pus).

Toxic shock syndrome due to streptococcal bacteria does not always include a rash. In addition, when TSS is caused by streptococcal, it is often linked to skin infections.

On the other hand, infections from staphylococcal bacteria usually have a rash and are more commonly associated with tampon use.

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.

Risk Factors

Some situations can make a person more at risk for developing the infections that cause TSS, including:

  • Menstruation
  • 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 for nosebleeds)
  • Recent miscarriage, abortion, or childbirth
  • An open wound, injury, or insect bite
  • Staph infection

It is important to note that a person who has had toxic shock syndrome before can get it again. That is why people who menstruate should avoid tampons to limit to the risk of recurrence.

A person who develops streptococcal TSS is also at a higher risk of serious complications, such as ARDS.

Causes

Two kinds of bacteria cause TSS:

  • Streptococcal
  • Staphylococcal

Once inside the body, streptococcal and staphylococcal bacteria produce exotoxins (toxins released by bacteria). Usually, your immune system protects you by identifying and destroying pathogens in your body. However, in the case of TSS, your immune system overreacts, mounting a major response to the toxins by releasing a cascade of immune cells called cytokines (sometimes called a cytokine storm).

This immune system over-activation leads to the symptoms of toxic shock syndrome. Untreated, the response overwhelms the body to the extent that multi-system organ failure and even death can occur.

Link to Tampon Use

Toxic shock syndrome is linked to tampon use. The most considerable risk associated with tampons and TSS is absorbency—super-absorbent tampons present a higher risk.

That's why you should avoid super-absorbent tampons, if possible, and use the lowest absorbency possible. Look for the right absorbency for your flow, rather than the one that will last the longest.

To reduce your risk of TSS from tampon use:

  • Change tampons regularly (every four hours).
  • Avoid super-absorbent tampons.
  • Use tampons immediately after unwrapping.
  • Wash hands well before inserting tampons.
  • Be gentle when inserting and removing.
  • Avoid applicators that could scratch the vagina.
  • Use alternate products, like pads or period underwear, overnight and when your period is light.
  • Only use tampons during your period.
  • Use lubricant to insert tampons on light days or if you experience vaginal dryness.
  • Do not use tampons if you have previously had TSS.

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.

Non-Menstrual Causes

While most toxic shock syndrome cases are associated with menstruation, it also occurs in people who are not menstruating (non-menstrual TSS). Non-menstrual causes include:

  • Soft-tissue infections
  • Post-surgical infections
  • Retained foreign items, like nasal packing or catheters

However, up to one-third of cases are not linked to any risk factor. Often streptococcal infections that can result in toxic shock syndrome occur in people who are otherwise healthy but who are recovering from a medical procedure, injury, or viral illness.

Recap

Streptococcal and staphylococcal bacteria cause TSS. Tampon use is the most common way these bacteria enter the body and lead to TSS. However, TSS is not only associated with menstruation. Anyone can get TSS. Other causes include soft tissue and post-surgical infections, and retained foreign items.

Diagnosis

People of all ages can develop toxic shock syndrome. In the United States, toxic shock syndrome occurs in about three per 100,000 menstruating people every year. But, it also occurs in those who do not menstruate.

While it's rare, the condition can be life-threatening—even in previously healthy people. In addition, the fatality rate of streptococcal TSS may be higher than 50%, while non-streptococcal TSS is less than 3%. Therefore, prompt diagnosis and treatment are critical.

The initial symptoms will depend on the bacteria causing the infection. In general, if a person has a high fever and rash that came on quickly and they also recently gave birth, had surgery, or used tampons, a healthcare provider may suspect toxic shock syndrome as the cause.

CDC Diagnostic Criteria

To help healthcare providers 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 criteria to help diagnose toxic shock syndrome:

  • Fever (102.02 degrees F or 38.9 degrees C)
  • Hypotension (low blood pressure, defined as systolic blood pressure reading of < 90 mmHg)
  • Characteristic, "sunburn-like" rash on palms of hands or bottom of feet
  • Desquamation (skin peeling) one to two weeks after the rash starts
  • Involvement of three or more organ systems including gastrointestinal (GI), musculoskeletal, cardiovascular (heart), renal (urinary and kidney), circulatory (blood), mucosal, and nervous system

In addition to the above criteria, a person must test negative for several other conditions that can cause similar symptoms, including measles and tick-borne illnesses.

Tests

As toxic shock syndrome results from the body's overreactive immune response to an infection, there is no specific test for the condition. Instead, a healthcare provider will assess your clinical symptoms and risk factors.

Several tests can confirm the presence of infection and identify streptococcal and staphylococcal bacteria. These include:

  • Blood tests to assess the activity of the immune system (such as looking at the number of white blood cells)
  • Blood tests to evaluate the function of specific body systems that may be affected, such as the liver, kidneys, or central nervous system
  • Urine or skin cultures to look for streptococcal or staphylococcal bacteria
  • Lumbar puncture (spinal tap) to check for bacteria

Multiple blood tests and cultures may be necessary 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, immediate, intensive medical intervention is needed to prevent potentially life-threatening complications.

People with TSS often require hospitalization and may spend time in the intensive care unit (ICU).

Recap

Diagnosing TSS involves evaluating symptoms and ruling out other potential causes like measles and tick-borne illnesses. Tests may include blood tests, urine or skin cultures, and a spinal tap.

Treatment

While toxic shock syndrome is uncommon, accurate and timely diagnosis and prompt treatment are essential. That's because it can take a couple of hours to a couple of days for the condition to turn life-threatening. Most people with the illness will require hospitalization.

Healthcare providers must determine the cause and source of the infection to provide proper treatment. If the condition is caused by something that can be removed (like a tampon), the first intervention is to remove the source.

Antibiotics

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 will depend on the bacteria causing the infection and the location of the infection. For example, FDA-approved oritavancin (Orbactiv) treats bacterial infections in skin wounds.

Some bacteria have grown resistant to antibiotics, so you may need multiple medications to treat the infection and prevent complications from TSS. The standard treatment course is seven to 14 days. You may need more prolonged treatment or additional treatment depending on the severity of the infection and whether complications arise.

Supportive Treatments

While being treated for the underlying infection, you may also receive supportive measures to help with symptoms like pain and dehydration. These interventions may include:

  • IV fluids and electrolyte replenishment
  • Pain medications
  • Antiemetics (anti-nausea medication)
  • Wound cleaning and debridement (unhealthy tissue removal)
  • Vasopressors (medicine to treat low blood pressure)

Recap

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.

Prevention

Once you've had toxic shock syndrome, you are at risk of developing it again. Therefore, if you menstruate, your healthcare provider will likely advise you to avoid using tampons and menstrual cups.

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

  • Frequently change tampons and avoid super-absorbent varieties.
  • Keep devices inserted into the vagina clean (such as cervical caps, diaphragms, and birth control rings).
  • Practice proper hygiene and wound care after surgery or medical procedures.
  • Be aware of the potential signs and symptoms of TSS when recovering from childbirth, miscarriage, or abortion procedures.
  • Receive timely treatment for complications that occur after illnesses like chickenpox.

Summary

TSS is a rare infection caused by streptococcal and staphylococcal bacteria. With TSS, these bacteria usually enter the body through things inserted in the body, like tampons, nasal packings, or catheters. It can also result from an infected wound, following childbirth, miscarriage, and abortion. Sometimes there is no apparent cause. Symptoms, including fever, rash, and low blood pressure, can escalate to shock quickly.

Prompt diagnosis and treatment are crucial because TSS can be fatal. Healthcare providers use blood tests, cultures, and lumbar punctures to diagnose the condition. First-line treatment is antibiotics and other supportive care. If you have TSS, you will be hospitalized while you receive treatment.

A Word From Verywell

Keep in mind that TSS is not dependent on menstruation. It occurs in adults and children of all ages and genders. While no specific vaccine or treatment prevents the condition, you can reduce the likelihood of getting the infection by avoiding known risk factors.

For example, if you menstruate, keep menstrual cups clean and disinfected, change your tampons frequently, and avoid super-absorbent tampons. In addition, be aware of signs and symptoms so that you can seek immediate medical treatment if necessary.

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9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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