Toxic shock syndrome

Definition

Toxic shock syndrome (TSS) is an uncommon, but potentially serious, illness that occurs when poisonous substances (toxins) produced by certain bacteria enter the bloodstream. The toxins cause a type of blood poisoning caused by staphylococcal, or less commonly streptococcal, infections in the lungs, throat, skin or bone, or from injuries. Women using super absorbent tampons during menstruation were found to be most likely to get toxic shock syndrome.

Description

TSS first came to the attention of the public in the 1970s. Shortly after the introduction of a super-absorbent tampon, young women across the United States experienced an epidemic of serious but unexplained symptoms. Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. The only thing they had in common was that they all were menstruating at the time they felt sick, and all were using tampons -- especially super absorbent products.

At its height, the epidemic affected 15,000 people in the United States each year between 1980 and 1984; 15% of the women died. Since the offending products were taken off the market, the numbers of TSS cases have declined sharply. As of 1998, only about 5,000 cases are diagnosed annually in the United States, 5% of which are fatal. The decline is most likely due to the tampon manufacturers' discontinuing the use of some synthetic materials, and the removal from the market of the brand of tampon associated with most cases of TSS. Today, most of these products are made with rayon and cotton.

In spite of TSS' association with menstruating women, the disease can affect anyone of either sex or any age or race. The infection may occur in children, men, and non-menstruating women who are weakened from surgery, injury, or disease, and who can not fight off a staphylococcal infection. New mothers are also at higher risk for TSS.

Most cases reported in the recent past, however, still involve menstruating women under age 30. TSS still occurs in about 17 out of every 100,000 menstruating girls and women each year; more than half of these cases are related to tampons. Between five and 10% of patients with TSS die.

Streptococcal toxic shock syndrome (STSS)

A new type of toxic shock syndrome is caused by a different bacteria, called Group A streptococcus. This form of TSS is called streptococcal toxic shock syndrome, or STSS. Officially recognized in 1987, STSS is related to the strain of streptococcus nicknamed the "flesh-eating bacterium." STSS affects only one or two out of every 100,000 Americans. It almost never follows a simple "strep throat" infection.

Causes & symptoms

Transmission

STSS is caused by a strain of Staphylococcus 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 infection.

While experts know the name of the bacterium, more than 10 years after the 1980s epidemic scientists still do not fully understand the link between TSS and tampons. Most medical researchers today suspect that the absorbent 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 more bacteria it can harbor. Some experts believe that the reason TSS is linked to tampons in particular is that bacteria can contaminate and multiply in a tampon. If left in place for a long time--as a woman could do with a super absorbent product--the bacteria have a better chance of multiplying and producing a large amount of toxin. It is also possible that the tampons or the chemicals they contain may irritate the vaginal lining, enabling the toxin to enter the bloodstream.

These type of bacteria are normally present either on hands or in the vagina, and it takes an amount of bacteria only the size of a grain of sand to start an infection. Of the 15% of women who carry Staphylococcus aureus, only about 5% have the strain that produces the TSS toxin.

Symptoms

TSS begins suddenly, with a high fever of 102°F (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 the blood pressure drops, a woman may become disoriented or go into shock. Her kidneys may fail. After these developments, the skin on her hands and feet may peel.

STSS can occur after a streptococcal infection in the body, usually from an infected wound or even chickenpox. Within 48 hours, the patient's blood pressure drops. There is also fever, dizziness, breathing problems, and a weak, rapid pulse. The area around the wound may swell, the liver and kidneys can fail, and bleeding problems may occur.

Diagnosis

Any woman who is wearing a tampon and begins to experience the symptoms of toxic shock syndrome should remove the tampon right away and seek medical care.

The doctor will probably examine the vagina for signs of inflammation and rule out common sexually transmitted diseases with similar symptoms. A variety of blood tests, tests of vaginal secretions, and a physical examination are needed to identify this condition.

Treatment

TSS

In a menstruating woman, the vagina is first cleansed with an antiseptic solution to eliminate some of the bacteria that produce the toxin. TSS is treated with antibiotics, together with other drugs and fluids to lower fever and control blood pressure.

STSS

Antibiotics are used to treat STSS. Surgery may be needed to remove dead skin and muscle.

Prognosis

TSS lasts as long as three weeks, and has a tendency to recur. About a third of the women who are treated for TSS have it again within six months. In addition, TSS can affect the liver, kidneys, lungs, and other organs, depending on the severity of the infection. Untreated toxic shock syndrome can be fatal.

Prevention

TSS

Women who wear tampons should change them often and use different brands and types of pads and tampons. If a woman really prefers tampons, experts recommend using the lowest possible absorbency product made of cotton and rayon, and wearing it only during the day. In the past, it was difficult to compare absorbency rates for different products. Today, the Food and Drug Administration (FDA) requires standardized absorbency measurements on all tampon boxes. Above all, women should wash their hands before inserting a tampon, and change the tampon every four to six hours.

Anyone who has had TSS even once should not use tampons again.

STSS

Doctors still are not sure how people can avoid STSS, but they advise patients to clean and bandage open wounds immediately. Anyone with a red, swollen, or tender wound, or a sudden fever should seek medical care.

Key Terms

Shock

A condition in which the amount of blood circulating in the body is inadequate to meet the body's needs. Shock can be caused by certain diseases, serious injury, or blood loss.

A genus of bacteria that is commonly found on human skin and mucous membranes.

A genus of sphere-shaped bacteria that can cause a wide variety of infections.

Toxin

A poisonous protein that is produced by some bacteria. A toxin is less complex than a poison.

Further Reading

For Your Information

Books

• Garrett, Laurie. The Coming Plague. New York: Penguin Books, 1994.
• Turkington, Carol A. Infectious Disease A to Z. New York: Facts on File, 1998.

  Periodicals

• "CDC defines group A streptococcal toxic shock syndrome." American Family Physician 47 (7)(May 15, 1993): 1643-1644.
• "Toxic shock syndrome -- United States." Morbidity and Mortality Weekly Report 46 (22) (June 6, 1997): 492-495.

  Other

• Kids Health. http://KidsHealth.org/parent/common/toxic_shock.html.

Gale Encyclopedia of Medicine. Gale Research, 1999.