Staphylococcus or streptococcus bacteria cause toxic shock syndrome. Women who use tampons are at risk of toxic shock syndrome. Read more at Meri Sehat.

Toxic Shock Syndrome

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Toxic shock syndrome (TSS) is described as an acute bacterial infection commonly caused by toxins produced by the bacteria Staphylococcus aureus (S. aureus) or Streptococcus pyogenes (S. pyogenes). Although rare, the illness is highly life-threatening. In the United States, the incidence of TSS ranges from 0.8-3.4 per 100,000<a href="#accordion">[2]</a>.&nbsp;

The disease first became evident in 1978 when multiple children began presenting with high fever, rash, and multi-organ failure<a href="#accordion">[1]</a>. Later, in the 1980s, the use of highly absorbent tampons among the female population was found to be causing TSS. Since the discontinuation of these highly absorbent tampons, the number of tampon-associated TSS cases has significantly declined<a href="#accordion">[2]</a>.&nbsp;However, tampon use is not the only risk factor. Moreover, it&rsquo;s not just young women; men and children of any age are also affected by TSS. Approximately, 25% of non-menstrual TSS cases occur in men<a href="#accordion">[3]</a>. 
&nbsp;

TSS is classified based on the causative organism<a href="#accordion">[2]</a>:&nbsp;

<ol>
	<li>Streptococcal TSS: As the name implies, the illness results from an infection with Streptococcus. It is not associated with tampon use.</li>
	<li>Non-Streptococcal TSS: This is commonly used to refer to cases caused by S. aureus.&nbsp;</li>
</ol>

&nbsp;

Another classification of TSS is based on the presence of menstruation:

<ol>
	<li>Menstrual TSS: These cases occur in menstruating women and are usually associated with tampon use. However, diaphragms, menstrual cups, and menstrual sponges have also been linked to menstrual TSS in women.&nbsp;</li>
	<li>Non-Menstrual TSS: Approximately 50% of cases occur in non-menstrual settings where the bacteria gain entry into the body<a href="#accordion">[3]</a>. Post-surgical infections, burns, soft tissue infections, and retained foreign bodies such as dialysis catheters can all lead to TSS.&nbsp; 
	&nbsp;</li>
</ol>

Signs And Symptoms

The signs and symptoms of TSS include:

<ul>
	<li>High fever, often accompanied by chills</li>
	<li>A rash resembling a sunburn is found mostly on soles and palms, and which later peels off&nbsp;</li>
	<li>Hypotension&nbsp;</li>
	<li>Vomiting</li>
	<li>Diarrhea</li>
	<li>Headache</li>
	<li>Sore throat, cough</li>
	<li>Seizures</li>
	<li>Malaise</li>
	<li>Confusion</li>
	<li>Myalgia</li>
</ul>

<div>&nbsp;</div>

Causes

The bacteria S. aureus and S. pyogenes are naturally present in women&rsquo;s reproductive tract, our skin, and mucous membranes. However, at times, these bacteria can multiply and produce toxins. Clostridium sordellii, which is typically present in the vagina, can also cause TSS.&nbsp;

Exotoxins produced by S. aureus, such as TSS toxin type-1 (TSST-1) and Staphylococcal enterotoxin B, are most commonly implicated in causing toxic shock syndrome. These toxins activate T-cells and lead to a cytokine storm, which brings on the multisystem disease.&nbsp;

However, it is unclear how tampons cause TSS. Researchers suggest that tampons are likely to cause entrapment of the bacteria, providing them with a suitable environment for growth, especially if the tampons are superabsorbent and left in place for a long time.&nbsp;

There&rsquo;s another theory that states tampons can cause slight tears in the vaginal wall, providing the bacteria with an entry into the bloodstream. In that case, tampons are not the only causative factor. Bacteria can also enter the bloodstream through cuts and open wounds, e.g., during surgery. Even nasal packing, as that conducted for nosebleeds, can cause the growth of bacteria.&nbsp;

Additionally, TSS can spread from person to person via direct contact.&nbsp; 
&nbsp;

There are currently no screening tests for TSS. 
&nbsp;

Diagnosis

The US Centers for Disease Control and Prevention (CDC) has proposed the following clinical criteria for diagnosis of TSS<a href="#accordion">[4]</a>:

&nbsp;

<ul>
	<li>
	<h5>Hypotension</h5>
	</li>
</ul>

For adults, a systolic blood pressure of less than or equal to 90 mmHg.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Multi-Organ Failure</h5>
	</li>
</ul>

This should present with any 2 or more of the following symptoms:

<ol>
	<li>Renal impairment, i.e., creatinine levels greater than or equal to 2 mg/dl, and pre-existing renal disease&nbsp;&nbsp;</li>
	<li>Coagulopathy, i.e., platelets less than or equal to 100.000/mm3 or disseminated intravascular coagulation</li>
	<li>Liver disease, i.e., elevated liver enzymes such as Alanine aminotransferase, aspartate aminotransferase, or total bilirubin</li>
	<li>Acute respiratory distress syndrome, which is characterized by hypoxemia, generalized <a href="https://www.merisehat.pk/disease/pulmonary-edema" target="_blank">edema</a>, and pulmonary infiltrates</li>
	<li>A macular rash that begins to peel or desquamate</li>
	<li>Soft-tissue necrosis&nbsp;</li>
</ol>

&nbsp;

Furthermore, the laboratory criteria for TSS are:

<ul>
	<li>Probable: The symptoms of these cases are not defined by any other illness and they also meet the clinical case definition. Moreover, the bacteria are isolated from a non-sterile site.</li>
	<li>Confirmed: Along with meeting the clinical case definition, there is the isolation of S. pyogenes from a sterile site, such as cerebrospinal fluid or blood.&nbsp;</li>
</ul>

&nbsp;

There is no specific test for TSS itself. Instead, doctors conduct blood and urine tests to check for S. aureus or S. pyogenes. Moreover, samples are swabbed from the nose, throat, vagina, and cervix for analysis. Due to the multi-system involvement, a CT scan, chest X-ray, or a lumbar puncture may also be conducted to assess for any complications.&nbsp; 
&nbsp;

Treatment

Since TSS has a bacterial cause, antibiotic therapy is often the first line of treatment. Aggressive intravenous antibiotics are administered as soon as possible. Hence, hospitalization is necessary for antibiotics and supportive treatment. Penicillin and clindamycin are often the first choice and are administered together.&nbsp;

Other than antibiotics, treatment can include drugs to stabilize blood pressure, electrolytes for dehydration, and gamma globulin injections to boost the immune system. Multi-organ failure, particularly the involvement of kidneys can be fatal without respective organ transplant and/or dialysis. Moreover, surgical debridement is necessary in cases of wound infection causing TSS.&nbsp;

Note: In case of TSS resulting from a tampon or vaginal sponge, it&rsquo;s important to immediately remove the foreign object from the body.&nbsp;

<div>&nbsp;</div>

TSS is a life-threatening illness. In particular, streptococcal TSS has a mortality rate of 30-70%.&nbsp;

&nbsp;

Other complications include:

<ul>
	<li>Multi-organ failure (e.g., renal failure, coagulopathy, liver failure, etc.)</li>
	<li>Rheumatic fever</li>
	<li>Shock&nbsp;</li>
</ul>

&nbsp;

&nbsp;

The common risk factors for TSS are:

<ul>
	<li>Using super-absorbent tampons</li>
	<li>Open wounds and cuts</li>
	<li>Post-surgical wound infections</li>
	<li>Nasal packing</li>
	<li>Dialysis catheters</li>
	<li>Recent <a href="https://www.merisehat.pk/disease/cold-flu" target="_blank">flu</a> infection</li>
	<li>Immunocompromised state</li>
	<li>History of TSS</li>
	<li><a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">Diabetes</a></li>
	<li>Chickenpox infection 
	&nbsp;</li>
</ul>

The following measures can help prevent the infection:

<ul>
	<li>Use the lowest absorbency tampons.</li>
	<li>Avoid using a tampon overnight.</li>
	<li>Change the tampon every 4-8 hours.</li>
	<li>Switch to a sanitary napkin for lighter flow days of the menstrual cycle.</li>
	<li>Avoid tampons if there&rsquo;s a history of staph or strep infection.</li>
	<li>Wash menstrual cups thoroughly before and after use.</li>
	<li>Follow package instructions for diaphragms and contraceptive sponges. 
	&nbsp;</li>
</ul>

Tampon use has been widely implicated as the most common factor in causing TSS. A nationwide study conducted in France discovered that wearing tampons for more than 6 hours increased the risk of TSS two-fold. Moreover, women who wore tampons overnight, i.e., for more than 8 hours, had a three-fold high risk of TSS<a href="#accordion">[5]</a>.&nbsp; 
&nbsp;

Key Points

<ul><li>Toxic shock syndrome (TSS) is a rare but life-threatening bacterial infection caused by toxins produced by the bacteria Staphylococcus aureus or Streptococcus pyogenes.</li><li>Researchers hint at tampons being the likely cause of entrapment of the bacteria since they provide the ideal environment for growth. This is more likely if the tampons are super-absorbent and left in place for a long time.</li><li>However, tampon use is not the only risk factor. Moreover, it’s not just the young women; men and children of any age can also be affected by TSS. Approximately, 25% of non-menstrual TSS cases occur in men.</li><li>A sudden, high fever, rash, hypotension, vomiting, diarrhea, headache, and confusion are common signs and symptoms of TSS.</li><li>TSS is a life-threatening illness as the symptoms can progress rapidly to complications, such as multi-organ failure, shock, and death.&nbsp;</li><li>The common risk factors for TSS are super-absorbent tampons, open wounds and cuts, post-surgical wound infections, nasal packing, dialysis catheters, recent flu infection, immunosuppression, and history of TSS.</li><li>There is no specific test for TSS. Instead, doctors conduct blood and urine tests to check for S. aureus or S. pyogenes. Moreover, samples are swabbed from the nose, throat, vagina, and cervix for culture and identification of causative organisms. A CT scan, chest X-ray, or a lumbar puncture may also be conducted to assess for any complications</li><li>A patient with high fever and vomiting (and using a tampon while menstruating) should immediately contact a healthcare professional.&nbsp;</li></ul><div> </div>

[1] Helgerson SD. Toxic-shock syndrome: tampons, toxins, and time: the evolution of understanding an illness. Women Health. 1981;6(3-4):93-104.

[2] Ross A, Shoff HW. Toxic Shock Syndrome. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[3] Ramesh Venkataraman MBBS. Toxic shock syndrome. Background, Pathophysiology, Etiology.

[4] Streptococcal Toxic Shock Syndrome: For clinicians. Centres for Disease Control and Prevention.

[5] Billon A, Gustin M-P, Tristan A, et al. Association of characteristics of tampon use with menstrual toxic shock syndrome in France. EClinicalMedicine. 2020;21:100308.