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Toxic Shock Syndrome (TSS)


Larry M. Bush

, MD, FACP, Charles E. Schmidt College of Medicine, Florida Atlantic University;

Maria T. Vazquez-Pertejo

, MD, FACP, Wellington Regional Medical Center

Reviewed/Revised May 2023
Topic Resources

Toxic shock syndrome is caused by staphylococcal or streptococcal exotoxins. Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which may rapidly progress to severe and intractable shock. Diagnosis is made clinically and by isolating the organism. Treatment includes antibiotics, intensive support, and IV immune globulin.

Toxic shock syndrome (TSS) is caused by exotoxin-producing cocci. Strains of phage-group 1 Staphylococcus aureus elaborate the TSS toxin-1 (TSST-1) or related exotoxins; certain strains of Streptococcus pyogenes produce at least 2 exotoxins.

Staphylococcal toxic shock

People at highest risk of staphylococcal TSS are

  • Women who have preexisting staphylococcal colonization of the vagina and who leave tampons or other devices (eg, menstrual cups, cervical caps, intrauterine devices, contraceptive sponges, diaphragms, pessaries) in the vagina

Mechanical or chemical factors related to tampon use probably enhance production of the exotoxin or facilitate its entry into the bloodstream through a mucosal break or via the uterus. Estimates suggest about 3 cases/100,000 menstruating women still occur, and cases are still reported in women who do not use tampons and in women who have infection after childbirth, abortion, or surgery. About 15% of cases occur postpartum or as a complication of postoperative staphylococcal wound infections that appear insignificant.

Staphylococcal TSS has also been reported in both men and women with any type of S. aureus infection.

Mortality resulting from staphylococcal TSS is < 3%.

Streptococcal toxic shock

Streptococcal TSS is similar to that caused by Staphylococcus aureus, but mortality is higher (20 to 60%) despite aggressive therapy. In addition, about 50% of patients have Streptococcus pyogenes bacteremia, and 50% have necrotizing fasciitis Necrotizing Soft-Tissue Infection Necrotizing soft-tissue infection is typically caused by a mixture of aerobic and anaerobic organisms that cause necrosis of subcutaneous tissue, usually including the fascia. This infection... read more Necrotizing Soft-Tissue Infection (neither is common with staphylococcal TSS). Patients are usually otherwise healthy children or adults.

Primary infections in skin and soft tissue are more common than in other sites. In contrast to staphylococcal TSS, streptococcal TSS is more likely to cause acute respiratory distress syndrome Acute Hypoxemic Respiratory Failure (AHRF, ARDS) Acute hypoxemic respiratory failure is defined as severe hypoxemia (PaO2 (See also Overview of Mechanical Ventilation.) Airspace filling in acute hypoxemic respiratory failure (AHRF) may result... read more Acute Hypoxemic Respiratory Failure (AHRF, ARDS) (ARDS) and less likely to cause a typical cutaneous reaction.

S. pyogenes TSS is defined as any group A beta-hemolytic streptococci (GABHS) infection associated with shock and organ failure.

Risk factors for GABHS TSS include

  • Minor trauma

  • Surgical procedures

  • Viral infections (eg, varicella)

  • Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Diabetes

  • Alcohol use disorder


  • 1. Schlievert PM, Davis CC: Device-associated menstrual toxic shock syndrome. Clin Microbiol Rev 33(3):e00032-19, 2020. doi: 10.1128/CMR.00032-19

Symptoms and Signs of Toxic Shock Syndrome

Onset of toxic shock syndrome is sudden, with

  • Fever (39 to 40.5° C, which remains elevated)

  • Hypotension (which can be refractory)

  • A diffuse macular erythroderma

  • Involvement of at least 2 other organ systems

Staphylococcal TSS is likely to cause vomiting, diarrhea, myalgia, elevated creatine kinase, mucositis, hepatic damage, thrombocytopenia, and confusion. The staphylococcal TSS rash is more likely to desquamate, particularly on the palms and soles, between 3 and 7 days after onset.

Streptococcal TSS commonly causes acute respiratory distress syndrome (in about 55% of patients), coagulopathy, and hepatic damage and is more likely to cause high fever, malaise, tachycardia, tachypnea, and, at the site of a soft-tissue infection, severe pain.

Renal impairment is frequent and common in both types of TSS.

TSS may progress within 48 hours to syncope, tissue necrosis, shock, disseminated coagulation, multisystem organ failure, and death. Less severe cases of staphylococcal TSS are fairly common.

Diagnosis of Toxic Shock Syndrome

  • Clinical evaluation

  • Cultures

Diagnosis of toxic shock syndrome (TSS) is made clinically and by isolating the organism from blood cultures (for Streptococcus) or from the local site.

Specimens for culture should be taken from any lesions, the nose (for staphylococci), throat (for streptococci), vagina (for both), and blood.

MRI or CT of soft tissue is helpful in localizing sites of infection.

Continuous monitoring of renal, hepatic, bone marrow, and cardiopulmonary function is necessary.

Differential diagnosis

TSS resembles Kawasaki disease Kawasaki Disease Kawasaki disease is a vasculitis, sometimes involving the coronary arteries, that tends to occur in infants and children between the ages of 1 year and 8 years. It is characterized by prolonged... read more Kawasaki Disease , but Kawasaki disease usually occurs in children < 5 years of age and does not cause shock, azotemia, or thrombocytopenia; the rash is maculopapular.

Other disorders to be considered are scarlet fever Scarlet fever Streptococci are gram-positive aerobic organisms that cause many disorders, including pharyngitis, pneumonia, wound and skin infections, sepsis, and endocarditis. Symptoms vary with the organ... read more Scarlet fever , Reye syndrome Reye Syndrome Reye syndrome is a rare form of acute encephalopathy and fatty infiltration of the liver that occurs almost exclusively in children The cause of Reye syndrome is unknown, but many cases seem... read more , staphylococcal scalded skin syndrome Staphylococcal Scalded Skin Syndrome Staphylococcal scalded skin syndrome is an acute epidermolysis caused by a staphylococcal toxin. Infants and children are most susceptible. Symptoms are widespread bullae with epidermal sloughing... read more Staphylococcal Scalded Skin Syndrome , meningococcemia Meningococcal Diseases Meningococci (Neisseria meningitidis) are gram-negative diplococci that cause meningitis and meningococcemia. Symptoms, usually severe, include headache, nausea, vomiting, photophobia... read more Meningococcal Diseases , Rocky Mountain spotted fever Rocky Mountain Spotted Fever (RMSF) Rocky Mountain spotted fever (RMSF) is caused by Rickettsia rickettsii and transmitted by ixodid ticks. Symptoms are high fever, severe headache, and rash. (See also Overview of Rickettsial... read more Rocky Mountain Spotted Fever (RMSF) , leptospirosis Leptospirosis Leptospirosis is an infection caused by one of several pathogenic serotypes of the spirochete Leptospira. Symptoms are biphasic. Both phases involve acute febrile episodes; the second... read more , and viral exanthematous diseases Exanthematous infections Categorizing viral infections by the organ system most commonly affected (eg, lungs, gastrointestinal tract, skin, liver, central nervous system, mucous membranes) can be clinically useful,... read more . These disorders are ruled out by specific clinical differences, cultures, and serologic tests.

Treatment of Toxic Shock Syndrome

  • Local measures (eg, decontamination, debridement)

  • Fluid resuscitation and circulatory support

  • Empiric antibiotic therapy (eg, clindamycin or linezolid plus vancomycin, daptomycin, linezolid, or ceftaroline) pending culture results

Patients suspected of having TSS should be hospitalized immediately and treated intensively. Tampons, diaphragms, and other foreign bodies should be removed at once.

Suspected primary sites should be decontaminated thoroughly. Decontamination includes

  • Reinspection and irrigation of surgical wounds, even if they appear healthy

  • Repeated debridement of devitalized tissues

  • Irrigation of potential naturally colonized sites (sinuses, vagina)

Fluids and electrolytes are replaced to prevent or treat hypovolemia, hypotension, and shock. Because fluid loss into tissues can occur throughout the body (because of systemic capillary leak syndrome and hypoalbuminemia), shock may be profound and resistant. Aggressive fluid resuscitation and circulatory, ventilatory, and/or hemodialysis support are sometimes required.

Obvious infections should be treated with antibiotics (for indications and doses, see table ). Pending culture results, clindamycin or linezolid (to suppress toxin production) plus vancomycin, daptomycin, linezolid, or ceftaroline—empiric choices that cover the most likely etiologic organisms—should be used. If a pathogen is isolated on culture, the antibiotic regimen is adjusted as needed, as for the following:

  • For group A streptococci: Clindamycin plus a beta-lactam

  • For methicillin-susceptible S. aureus (MSSA): Clindamycin plus oxacillin or nafcillin

  • For methicillin-resistant Staphylococcus aureus (MRSA): Vancomycin or daptomycin plus clindamycin or linezolid, depending on the susceptibility

Antibiotics given during the acute illness may eradicate pathogen foci and prevent recurrences. Passive immunization to TSS toxins with IV immune globulin (2 g/kg, followed by 0.4 g/kg daily for up to 5 days) has been helpful in severe cases of both types of TSS and lasts for weeks, but the disease may not induce active immunity, so recurrences are possible.

If a test for seroconversion of the serum antibody responses to TSST-1 in acute- and convalescent-phase paired sera is negative, women who have had staphylococcal TSS should probably refrain from using tampons and menstrual cups, cervical caps, contraceptive sponges, intrauterine devices, diaphragms, and pessaries. Advising all women, regardless of TSST-1 antibody status, to change tampons frequently or use napkins instead and to avoid hyperabsorbent tampons seems prudent.

Key Points

  • Toxic shock syndrome (TSS) is caused by exotoxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes.

  • Although classically described as occurring with tampon use, TSS may occur after many staphylococcal or streptococcal soft-tissue infections.

  • Onset of symptoms is sudden; symptoms include high fever, hypotension (which can be refractory), diffuse erythematous rash, and multiple organ dysfunction.

  • Provide aggressive supportive care, and decontaminate and/or debride the source site.

  • Give antibiotics (eg, clindamycin or linezolid plus vancomycin, daptomycin, linezolid, or ceftaroline) pending culture and susceptibility testing.

  • Give IV immune globulin if TSS is severe.

Drugs Mentioned In This Article

Drug Name Select Trade
Cleocin, Cleocin Ovules, Cleocin Pediatric, Cleocin T, CLIN, Clindacin ETZ, Clindacin-P, Clinda-Derm , Clindagel, ClindaMax, ClindaReach, Clindesse, Clindets, Evoclin, PledgaClin, XACIATO
Zyvox, Zyvox Powder, Zyvox Solution
FIRVANQ, Vancocin, Vancocin Powder, VANCOSOL
Cubicin, Cubicin RF
No brand name available
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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