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Toxic Shock Syndrome

What is toxic shock syndrome?

Toxic shock syndrome, or TSS, describes a cluster of symptoms that involve many systems of the body. The following bacteria commonly cause TSS:

  • Staphylococcus aureus
  • Streptococcus pyogenes

TSS from Staphylococcus infections was identified in the late 1970s and early 1980s when highly absorbent tampons were widely used in menstruating women. Due to manufacturing changes in tampons, the incidence of tampon-induced TSS has declined.

TSS from streptococcus infections is most commonly seen in children and the elderly. Other populations at risk include individuals with diabetes, HIV, chronic lung disease, or cardiac disease.

How is toxic shock syndrome transmitted?

  • staphylococcus infections
    Staphylococcus aureus (or S. aureus) may normally exist in a person's nose or vagina and not cause infection. Because it is part of the body's normal bacteria, 90 percent of individuals develop antibodies to prevent infection. S. aureus can be transmitted by direct contact with infected persons. Individuals who develop TSS, usually have not developed antibodies against S. aureus. Therefore, it is not usually considered a contagious infection. S. aureus infections may also occur from another infection such as pneumonia, sinusitis, osteomyelitis (infection in the bone), or skin wound, such as a burn or surgical site. If any of these areas are infected, the bacteria can penetrate into the bloodstream.
  • streptococcus infections
    Streptococcus pyogenes (or S. pyogenes) TSS may occur as a secondary infection. Most commonly, this is seen in individuals who have recently had chickenpox or bacterial cellulitis (infection of the skin and underlying tissue).

What are the symptoms of toxic shock syndrome?

The following are the most common symptoms of TSS. However, each child may experience symptoms differently. Symptoms of TSS involve many systems and may include:

Centers for Disease Control and Prevention (CDC) criteria for staphylococcus TSS:

  • fever of 102º F or higher
  • chills
  • malaise (uneasiness and despair)
  • headache
  • fatigue
  • red, flat rash that covers most of the areas of the body
  • shedding of the skin in large sheets especially over the palms and soles (this is seen one to two weeks after the onset of symptoms)
  • low blood pressure
  • vomiting
  • diarrhea
  • muscle pain
  • increased blood flow to mouth, eyes, and vagina making them appear red
  • decreased urine output and sediment in urine
  • decreased liver function
  • bruising due to low blood platelet count
  • disorientation and confusion

Centers for Disease Control and Prevention (CDC) criteria for streptococcal TSS:

  • dangerously low blood pressure
  • shock
  • decreased kidney function
  • bleeding problems
  • bruising due to low blood platelet count
  • red, flat rash that covers large areas of the body
  • liver problems
  • shedding of the skin in large sheets especially over the palms and soles (this does not always occur)
  • difficulty breathing

The symptoms of TSS may resemble other medical conditions. Always consult your child's physician for a diagnosis.

What causes streptococcal and staphylococcal TSS?

Possible causes of streptococcal and staphylococcal TSS may include the following:

  • a history of using super-absorbent tampons
  • surgical wounds
  • a local infection in the skin or deep tissue
  • history of using a diaphragm or contraceptive sponge
  • history of childbirth or abortion

How is toxic shock syndrome diagnosed?

Ruling out similar illnesses, such as Rocky Mountain Spotted Fever, among others, is critical in diagnosing TSS. In addition, confirmation is made in children and adults who meet the CDC criteria for TSS. Other diagnostic studies may include:

  • blood cultures - usually cultures are not positive with staphylococcal infections and only 50 to 60 percent of the time in streptococcal infections.
  • blood tests (to measure blood clotting and bleeding times, cell counts, electrolytes, and liver function among others)
  • urine tests
  • lumbar puncture (spinal tap) - a special needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain can then be measured. A small amount of cerebral spinal fluid (CSF) can be removed and sent for testing to determine if there is an infection or other problems. CSF is the fluid that bathes your child's brain and spinal cord.

Treatment for toxic shock syndrome:

Specific treatment for streptococcal and staphylococcal TSS will be determined by your child's physician based on:

  • your child's age, overall health, and medical history
  • extent of the disease
  • your child's tolerance for specific medications, procedures, or therapies
  • expectations for the course of the disease
  • your opinion or preference

Treatment for TSS may include:

  • intravenous (IV) antibiotics
  • intravenous (IV) fluids (to treat shock and prevent organ damage)
  • cardiac medications (in patients with very low blood pressure)
  • dialysis (may be required in children who develop kidney failure)
  • administration of blood products
  • supplemental oxygen or mechanical ventilation (to assist with breathing)
  • deep surgical cleaning of an infected wound

Prevention of toxic shock syndrome:

The following may help prevent TSS:

  • Menstruating girls and women should avoid using tampons if they have had TSS, as reinfection is common.
  • Prompt and thorough wound care is crucial in avoiding TSS.
  • Minimal usage of vaginal foreign body items such as diaphragms, tampons, or sponges helps to reduce the risk of TSS.

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Online Resources of Infectious Diseases

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