Toxic Shock Syndrome (TSS)

What is Toxic Shock Syndrome (TSS)

Toxic shock syndrome is a condition that occurs when certain bacteria enter the body and release poisons called exotoxins into the bloodstream. The poisons can damage organs, such as the bowel, kidneys, lungs, and brain.

TSS is life-threatening and must be treated as soon as possible. The condition can result in:

  • Shock.
  • Organs failing.
  • Lung damage.
  • Respiratory failure.
  • Rash and ulcers.
  • Blood clotting and bleeding problems.

The condition can get worse very quickly and spread to other body parts.

7 Interesting Facts of Toxic Shock Syndrome

  1. Severe systemic disease caused by certain toxin-producing strains of Staphylococcus aureus or group A streptococcus
  2. Like MIS-C, patients present with fever and rash; hypotension, thrombocytopenia, central nervous system involvement (eg, confusion), and renal failure are common; a subset of patients with MIS-C fulfills clinical criteria for toxic shock syndrome
  3. History of retained foreign body (eg, tampon, nasal packing material) may be elicited
  4. Edema is generally diffuse and not limited to hands and feet; articular signs are generally absent
  5. Case definitions include hypotension and multisystem involvement
    • Features of nonstreptococcal toxic shock syndrome: 
      • Fever (39 °C or higher)
      • Generalized erythroderma followed by desquamation
      • Hypotension (systolic pressure lower than 90 mm Hg in adults and older adolescents or less than fifth percentile for age in children younger than 16 years)
      • Multiorgan involvement characterized by 3 or more of the following:
        • Gastrointestinal symptoms (vomiting or diarrhea, usually at onset of illness)
        • Muscle involvement (severe myalgias and/or creatine phosphokinase level twice reference range or higher)
        • Mucus membrane changes (hyperemia of conjunctivae, oropharynx, or vagina)
        • Renal impairment (BUN or creatinine level twice upper reference limit or higher or urinary sediment with pyuria in absence of urinary tract infection)
        • Hepatic impairment (transaminase or bilirubin level twice reference range or higher)
        • Coagulopathy (platelet count 100,000/mm³ or less)
        • Central nervous system manifestations (confusion, altered level of consciousness)
      • Cultures are negative (other than Staphylococcus aureus, which may or may not be found)
      • No serologic evidence of recent Rocky Mountain spotted fever, leptospirosis, or measles
    • Features of streptococcal toxic shock syndrome 
      • Hypotension (systolic pressure less than 90 mm Hg in adults and older adolescents or less than fifth percentile for age in children younger than 16 years)
      • Multiorgan involvement characterized by 2 or more of the following:
        • Renal impairment (creatinine level 2 mg/dL or higher for adults or twice upper reference limit or higher for age)
        • Coagulopathy (platelet count 100,000/mm³ or less or presence of disseminated intravascular coagulation)
        • Hepatic impairment (transaminase or bilirubin level twice reference range or higher)
        • Acute respiratory distress syndrome
        • Generalized erythematous rash; may desquamate
        • 1 or more sites of soft tissue necrosis
      • Isolation of group A streptococcus

What are the causes?

This condition is often caused by one of these types of bacteria:

  • Staphylococcus aureus.
  • Streptococcus pyogenes, or Group A streptococci (GAS).

Normally, these types of bacteria live on the skin or in mucous membranes without causing problems. TSS occurs after these bacteria enter the body through breaks, cracks, or wounds in the skin or other body tissue. TSS can develop if the bacteria grow out of control.

What increases the risk?

You are more likely to develop this condition if you:

  • Recently had surgery.
  • Have a viral infection, such as chicken pox (varicella) or viral pneumonia.
  • Have an open wound.
  • Have a Staphylococcus aureus skin infection.
  • Have foreign material inside your body, such as packings to stop nosebleeds.
  • Have diabetes.
  • Use tampons, especially super-absorbent tampons, and do not change them often.
  • Use certain barrier methods of birth control, such as a diaphragm, vaginal sponge, or cervical cap.
  • Recently gave birth.
  • Recently had a procedure involving the sex organs.

What are the signs or symptoms?

Symptoms of this condition include:

  • Fever.
  • Muscle aches.
  • Nausea and vomiting.
  • Diarrhea.
  • Headaches.
  • Red rash that looks like sunburn.
  • Redness of the mouth, throat, or eyes.
  • Light-headed feeling or dizziness, especially when going from a lying or sitting position to standing.
  • An infected wound. This may include:
    • Redness, swelling, or pain around a wound.
    • Fluid, blood, or pus coming from a wound.
  • Confusion.
  • Feeling very tired (lethargic).
  • Swelling or peeling of the skin, especially around the nails and on the soles of the feet and the palms of the hands.

How is this diagnosed?

This condition may be diagnosed based on your symptoms, your medical history, and a physical exam. You may have tests that check for bacteria and confirm the diagnosis, including:

  • Blood tests.
  • Urine tests.
  • A test of a fluid sample from the nose, throat, vagina, skin, spine, or wound.
  • Imaging tests such as X-rays, MRI, and CT scans.

How is this treated?

This condition is treated in the hospital. Treatment may include:

  • Antibiotic medicines.
  • Removal of any foreign material in the body.
  • IV fluids and medicines that raise blood pressure and replace fluids and body salts (electrolytes) that were lost from vomiting or diarrhea.
  • Medicine to raise blood pressure.
  • A procedure to clear away damaged or infected skin (debridement).
  • Dialysis.
  • Breathing support.

Follow these instructions at home:

  • Take over-the-counter and prescription medicines only as told by your health care provider.
  • If you were prescribed antibiotic medicine, take it as told by your health care provider. Do not stop taking the antibiotic even if you start to feel better or your condition improves.
  • Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
  • If you have a wound, follow instructions from your health care provider about how to take care of it.
  • If you are a woman, do not use tampons until the condition goes away.
  • Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

For men and women:

  • Understand how to take care of wounds properly to prevent infection.
  • Do not use gauze packing for a nosebleed.
  • Care for your tattoos and piercings properly.

For women:

  • If you use tampons or barrier methods of birth control:
    • Do not use them for more than 12 hours or as told by your health care provider.
    • Do not use them for 12 weeks after delivering a baby.
    • Before you insert or remove them, wash your hands with soap and warm water.
  • If you use tampons:
    • Alternate the use of tampons with sanitary napkins or pads during your period.
    • Try not to scratch the vaginal lining when inserting a tampon. Plastic applicators may make scratches more likely. If your vagina seems dry, use a water-soluble lubricating jelly to insert the tampon.
    • Avoid using super-absorbent tampons. Choose tampons that have the lowest absorbency that meets your needs.
    • Only use tampons that are 100% cotton.
    • Change your tampon every 4–8 hours.
    • If you sleep with a tampon in, put in a fresh tampon before you sleep and remove it immediately upon waking, or use sanitary napkins or pads at night. Do not leave a tampon inserted overnight if you plan to sleep more than 6–8 hours.
    • If you develop a fever or a rash while using a tampon, remove the tampon immediately.
    • Do not use tampons between periods.

Contact a health care provider if:

  • You are a woman who has delivered a baby within the past 12 weeks and you are exposed to someone who has a confirmed case of strep throat.

Get help right away if:

  • Your symptoms do not improve with treatment.
  • Your symptoms get worse.
  • You have:
    • Severe headache.
    • Severe bruising.
    • Chest pain or difficulty breathing.
    • Sudden or severe pain in your abdomen.
    • Sudden bleeding from your nose or gums.
    • Severe dizziness, or you faint.
  • Your symptoms return after your condition improves.

Summary

  • Toxic shock syndrome (TSS) is a condition that occurs when certain bacteria enter the body and release poisons called exotoxins into the bloodstream.
  • TSS is life-threatening and must be treated as soon as possible.
  • This condition is treated in the hospital.
  • If you were prescribed antibiotic medicine, take it as told by your health care provider. Do not stop taking the antibiotic even if you start to feel better or your condition improves.
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