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Toxic Shock Syndrome

by Matthew E. Levison, MD

Toxic shock syndrome is a group of rapidly progressive and severe symptoms that include fever, rash, dangerously low blood pressure, and failure of several organs. It is caused by toxins produced by Staphylococcus aureus or group A streptococci.

  • Using superabsorbent tampons or having an infection caused by Staphylococcus aureus or group A streptococci increases the risk of this syndrome.

  • The syndrome can be fatal, particularly when caused by streptococci.

  • Changing tampons frequently and not using superabsorbent tampons can help reduce the risk of the syndrome.

  • Treatment focuses on relieving symptoms and preventing production of more toxin.

Toxic shock syndrome results from toxins produced by Staphylococcus aureus or group A streptococci. It may occur when Staphylococcus aureus infects tissue (for example, in a wound) or is simply growing on a tampon (especially the superabsorbent type) in the vagina. Exactly why superabsorbent tampons increase the risk of this syndrome is unknown. Leaving a diaphragm in the vagina for more than 24 hours also increases the risk slightly. This syndrome may also occur in the following situations:

  • When a surgical incision is infected, even when the infection seems minor

  • When the uterus becomes infected after delivery of a baby

  • After nose surgery if bandages are used to pack the nose

  • In otherwise healthy people who have a group A streptococcal tissue infection, usually of the skin

Symptoms

If staphylococci or streptococci are the cause, symptoms develop suddenly and worsen rapidly over a few days. People may have a high fever, a red and sore throat, red eyes, diarrhea, and muscle aches. A rash that resembles sunburn covers the entire body, including the palms and soles. Then, the skin peels. Blood pressure falls to dangerously low levels, and people become delirious. Fluid accumulates in tissues, causing swelling (edema). Blood does not clot normally, making bleeding more likely and more severe. Several organs such as the kidneys, liver, heart, and lungs may malfunction or stop functioning.

In streptococcal toxic shock syndrome, the wound is painful. Gangrene may develop around the wound.

When streptococci are involved, up to 70% of people die. When staphylococci are involved, 5% of people die if the syndrome is related to menstruation, and 15% die if it is not. If people survive, recovery is usually complete.

When the source is a tampon infected by staphylococci, the syndrome may recur, usually within 4 months of the first episode. Occasionally, the syndrome recurs more than once. Each episode tends to be milder. To reduce the risk of recurrences, women who have had the syndrome should not use tampons or diaphragms.

Diagnosis

The diagnosis is usually based on the symptoms and results of a physical examination and routine blood tests. Samples of blood and infected tissue are sent to a laboratory where bacteria can be grown (cultured).

Prevention

Women who use tampons can take several measures to prevent infection:

  • Not using superabsorbent tampons

  • Using the least absorbent tampons needed

  • Alternating use of tampons and pads

  • Changing tampons every 4 to 8 hours

Otherwise, there are no recommendations for preventing toxic shock syndrome.

Treatment

If toxic shock syndrome is suspected, people are hospitalized, usually in an intensive care unit. Fluids that contain salts and often drugs to increase blood pressure to normal levels are given intravenously. Many people need help with breathing, usually with a mechanical ventilator. Tampons, diaphragms, and other foreign objects are removed from the vagina promptly. Antibiotics and, for severe cases, immune globulin (which can neutralize the toxin) are given intravenously. Areas that could contain the bacteria, such as surgical wounds and the vagina, are flushed out with water (irrigated).

If wounds are infected, surgery may be needed to clean them out further, to remove infected tissue, or sometimes, if gangrene has developed, to remove a limb.