Toxic Shock Syndrome

ByLarry M. Bush, MD, FACP, Charles E. Schmidt College of Medicine, Florida Atlantic University
Reviewed/Revised Mar 2023

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 the gram-positive 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 toxic shock syndrome.

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

  • Doctors diagnose toxic shock syndrome by doing a physical examination and by culturing and identifying the bacteria.

  • Treatment includes cleaning of the infected area, removing infected tissue, and using antibiotics.

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

(See also Overview of Bacteria.)

Causes of Toxic Shock Syndrome

Toxic shock syndrome results from toxins produced by two types of bacteria:

This syndrome 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 increases the risk slightly.

Toxic shock syndrome caused by group A streptococci usually occurs in people who have infection of skin or of tissues under the skin. About half of people with this syndrome have a bloodstream infection (bacteremia), and about half have necrotizing fasciitis (a particularly serious streptococcal infection).

Toxic shock 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 of Toxic Shock Syndrome

Toxic shock syndrome symptoms and prognosis vary depending on whether staphylococci or streptococci are the cause.

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

In streptococcal toxic shock syndrome, the infected wound, if present, is painful. Gangrene may develop around the wound. This syndrome is more likely to cause fever, a general feeling of illness (malaise), and severe pain at the site of the infection. Difficulty breathing due to respiratory failure (acute respiratory distress syndrome) is common. Even with treatment, 20 to 60% of people die.

Staphylococcal toxic shock syndrome is often less serious. Fewer than 3% of people die. Skin peeling, particularly on the palms and soles, is more common. The skin usually starts peeling 3 to 7 days after symptoms start. If people survive, recovery is usually complete.

When the source is a tampon infected by staphylococci, toxic shock syndrome commonly recurs, usually within 4 months of the first episode, if women continue to use tampons. 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 of Toxic Shock Syndrome

  • A doctor's evaluation

  • Culture of samples of blood and infected tissue

The diagnosis of toxic shock syndrome is usually based on the symptoms and results of a physical examination and routine blood tests.

Samples of blood and infected tissue are also sent to a laboratory where bacteria can be grown (cultured).

Magnetic resonance imaging (MRI) or computed tomography (CT) may be done to locate sites of infection.

Blood tests are done regularly to monitor how well organs are functioning.

Treatment of Toxic Shock Syndrome

  • Fluids given intravenously

  • Often medications to increase blood pressure

  • Cleaning of the infected area (vagina or wound) and removing infected tissue

  • Antibiotics

If toxic shock syndrome is suspected, people are hospitalized, usually in an intensive care unit (ICU).

Fluids that contain salts and often medications 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. Immune globulin contains antibodies obtained from the blood of people with a normal immune system. Antibiotics are started immediately, before the bacteria are identified. Once the bacteria are identified, antibiotics are adjusted as needed.

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.

Prevention of Toxic Shock Syndrome

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

Women who have had toxic shock syndrome due to staphylococci should probably not use tampons and cervical caps, plugs, or diaphragms.

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