Toxic shock syndrome

Definition

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness that occurs when poisonous substances (toxins) produced by bacteria enter the bloodstream. The toxins cause a type of blood poisoning that results in high fever , symptoms of shock, and potentially organ failure.

Description

Initially toxic shock syndrome was associated with the use of ultra-absorbent tampons by menstruating girls and women. Between 1978 and 1980 thousands went to emergency rooms with high fever, vomiting , low blood pressure, diarrhea , and a rash resembling sunburn . Once ultra-absorbent tampons were taken off the market, the number of cases of toxic shock syndrome decreased substantially.

As of 2004, two different causes of toxic shock were recognized. Staphylococcal toxic shock syndrome (TSS) is caused by the bacteria Staphylococcus aureus. Streptococcal toxic shock syndrome (STSS, first described in 1987, is caused by Streptococcus pyogenes bacteria. Although both types of toxic shock are rare, STSS is more common and has a higher rate of serious complications and death.

Transmission

TSS is caused by a strain of S. aureus found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the bloodstream, causing a potentially fatal reaction.

Although scientists still do not fully understand the link between TSS and tampons, most medical researchers suspect that tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body. Oxygen triggers bacterial growth, and the more absorbent the tampon, the longer it is left in place and the more toxin-producing bacteria it can harbor.

The streptococcal bacteria that cause STSS often enter the body through an infected wound in the skin, infection following surgery, postpartum or post abortion infection, or bone infection. STSS almost never develops following a simple strep throat infection.

Demographics

Although the majority of cases of TSS occur in menstruating girls and women, the disease may occur in people of any race and age, including children. STSS infection may occur in individuals who are weakened from surgery, injury, or disease that weakens the immune system. New mothers also are at higher risk for toxic shock syndrome, as are those who have recently had chicken pox. This disease is rare. Only about 100 cases of TSS and 300 cases of STSS were reported in the United States in 1996.

Causes and symptoms

Toxic shock syndrome begins suddenly about two days after infection occurs with a fever of 102°(38.9°C) or above, vomiting and watery diarrhea, headache , and sunburn-like rash, together with a sore throat and body aches. Blood pressure may plummet a day or two after the first symptoms appear. When blood pressure drops, an individual may become disoriented or go into shock. The kidneys or liver may fail. After these developments, the skin on the hands and feet may peel. With STSS, flesh around the infected site may become damaged and die (become necrotic).

When to call the doctor

Toxic shock is a medical emergency that needs to be treated immediately in the hospital. Parents should go to the emergency room or call an ambulance if their child has a fast, weak pulse; cold hands and feet with pale moist skin; mental confusion or lethargy; abnormal breathing; a sunburn-like rash; high fever; or skin that is red, swollen, and infected.

Diagnosis

Diagnosis is made based on history, presenting symptoms, and culture of bacteria from the blood or wound. A rapid streptococcal test can be done with results available in 15 minutes. This test is positive in more than 85 percent of cases of toxic shock.

Treatment

Because toxic shock is a medical emergency, treatment is usually begun before laboratory results are available. The first line of treatment is to attempt to reverse the symptoms of shock. This process usually involves the administration of fluids intravenously. The site of infection is cleaned, and antibiotics are administered. If organ failure occurs, oxygen, the use of a respirator, or kidney dialysis may be necessary. It may also be necessary to surgically remove any infected and dying tissue.

Prognosis

Many otherwise healthy individuals recover from toxic shock in two to three weeks; however, the length of recovery is variable and depends on how early and how aggressively the disease is treated. About 3 percent of individuals with TSS die. The death rate with STSS can be as high as 30 to 70 percent.

Prevention

Women and girls who use tampons should always wash their hands before inserting a tampon and change the tampon every four to six hours. Skin wounds should be cleaned with an antiseptic and covered with a bandage.

Parental concerns

Although the risk of TSS is very low, parents may prefer that their daughters use pads rather than tampons when menstruating.

Resources

BOOKS

Marx, John. Rosen's Emergency Medicine: Concepts and Clinical Practice , 5th ed. St. Louis: Mosby, 2002.

PERIODICALS

"A Quick Diagnosis of Toxic Shock Syndrome Is Critical for Avoiding Mortality." Health & Medicine Week (December 1, 2003): 616.

WEB SITES

Sharma, Sat, and Godfrey Harding. "Toxic Shock Syndrome." eMedicine Medical Library , January 22, 2003. Available online at http://www.emedicine.com/med/topic2292.htm (accessed October 4, 2004).

Tish Davidson, A.M.