Common Bacterias Can Cause Quite a Toxic Shock!

Although first described in children in 1978, most people became familiar with Toxic Shock Syndrome (TSS) in the early 1980s, when 812 cases of menstrual-related TSS were reported.[1]. That outbreak was linked to the newly developed, super-absorbent tampons dominating the feminine hygiene market at the time. Proctor & Gamble’s “Rely” tampon, made of highly absorbent synthetic fibers including polyester sponges and chips of carboxy-methyl-cellulose, was particularly implicated and subsequently pulled from the market.[2] Since that time, due in part to tampon manufacturing changes and consumer awareness, the incidence of tampon-induced TSS has diminished by more than 40%[3]. The overall incidence of TSS in the United States is approximately 5-10 cases per 100,000 population, with an estimated 77-93% of those cases occurring in women. Likewise, the TSS mortality rate has also declined from 5.6% to 3.3%.[4]

Both menstrual and non-menstrual forms of TSS are caused by the release of exotoxins,* such as Toxic Shock Syndrome Toxin 1 (TSST-1), from strains of the common bacterias Staphylococcus Aureus and Streptococcus Pyogenes.[5] It is only when the bacteria – uncommonly – begins to secrete such poisonous toxins that the disease occurs. If not treated, the toxin production leads to the development of high fever, rash, dangerously low blood pressure, shock, multiple organ failure, and in some cases, ultimately even death.

While TSS is commonly associated with tampon use in menstruating women, men, children and non-menstruating women of all ages can also develop TSS. Possible sources of TSS in addition to tampon usage include surgical wounds (including packing following nasal surgery), childbirth, long-term usage of a diaphragm, skin wounds such as those related to chickenpox, and other localized infection.[6] TSS cannot normally be passed from person to person.

TSS can affect any organ system within the body, including skin, lungs, liver, kidneys, circulatory and pancreatic. Symptoms include a fever greater than 102Ã?°F (38.9Ã?°C), TSS Rash (a flat, sunburn-like rash covering most of the body), “Strawberry Tongue”**, headache, muscle aches, sore throat, cough, nausea and vomiting, profuse diarrhea, abdominal pain, fainting, confusion and disorientation, low blood pressure (systolic less than 90 mm Hg) and in women with menstrual related TSS, vaginal inflammation and discharge.

Although no specific test exists to diagnose TSS, it can be suspected based on a specific cluster of symptoms. Diagnostic evaluations are performed to check for such criteria as abnormal electrolytes, hypotension, an elevated white blood count and liver or kidney dysfunction. In menstrual related cases, vaginal discharge and inflammation may also be present. Chest XRays, electrocardiograms and tests to rule out other conditions, i.e., Rocky Mountain Spotted Fever, will also be performed.

The Centers for Disease Control & Prevention criteria for the diagnosis of Staphylococcal TSS requires the presence of all of the following symptoms:[7]

TSS Rash
Involvement of 3 or more organ systems
Absence of evidence of Rocky Mountain Spotted Fever, leptospirosis, measles and hepatitis B
Antinuclear antibody
Positive Venereal Disease Research Laboratory (VDRL) test results, and
Antibodies at Monospot testing.

Similarly, the CDC’s criteria for Streptococcal TSS are:[8]

Isolation of Group A Streptococcus from a normally sterile site (e.g., blood, cerebrospinal fluid [CSF], surgical wounds) or a non-sterile site (such as throat)
hypotension, and
involvement of 2 or more organ systems.

Once diagnosed, treatment is begun immediately. In cases where the source of infection is a tampon or other packing (i.e., intra-nasal), removal of the object is performed. Antibiotics (including Nafcillin, Oxacillin, Penicillin, and/or Clindamycin) and fluids are given intravenously. Medication like Dopamine or Epinephrine is given to raise blood pressure and organ function is closely monitored. In advanced cases, oxygen may be needed; ventilator assistance is sometimes even required. In cases where the infection is found in deeper tissue, extensive surgery is sometimes necessary to remove the infected and/or necrotic skin.

Though there is no way to prevent Toxic Shock, risk of TSS can be reduced by:

Not using tampons altogether or alternating between tampons and pads
Using the lowest absorbency tampons available
Frequently changing tampons throughout the cycle
Never leaving a diaphragm in for more than 24 hours
Avoidance of the use of packing to stop nosebleeds, and
Keeping cuts, burns and surgical incisions clean and free of infection.

If you or a loved one begins to experience any signs of TSS, call your doctor or visit your nearest emergency room immediately. Early awareness and medical intervention is the key to effective and even life-saving treatment.

**strawberry tongue is characterized by red bumps rising above a yellowish/white coating on the tongue.

[1] Sara E Cosgrove, MD and Dori F Zaleznik, MD. Staphylococcal toxic shock syndrome.
[2] Brenda Mitchell. Toxic Shock Syndrome –
[3] University of Virginia Health System. Toxic Shock Syndrome.
[4] Robert W. Tolan, Jr., MD, Chief of Pediatric Infectious Diseases, St. Peter’s University Hospital and Capital Health System, Clinical Associate Professor of Pediatrics, Drexel University College of Medicine. Toxic Shock Syndrome.
[5] Dermnet. Toxic Shock Syndrome.
[6] Joseph S Bushra, MD, FAAEM, Adjunct Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Temple University School of Medicine; Attending Physician, The Lankenau Hospital, Wynnewood, Pennsylvania. Toxic Shock Syndrome.
[7], [8] Dane Salandy, MD. Toxic Shock Sydrome Clinical Work-Up.

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