infectious diseases

Toxic shock syndrome (TSS)

What is TSS?

Toxic shock syndrome (TSS) is a multisystem inflammatory response determined by bacterial strains capable of producing certain types of exotoxins.

An infection caused by Staphylococcus aureus and Streptococcus pyogenes, increases the risk that this rare complication may occur. The onset of toxic shock syndrome can localize at any body site, even if it occurs frequently following vaginal colonization, especially if present during the menstrual period. Indeed, the toxic shock syndrome was identified in the early 1980s and immediately associated with the use of internal pads. In the following years, thanks to the introduction of some production changes and the removal of some products from the market, the incidence of TSS associated with the use of internal tampons has decreased. At the same time, women have become more aware of the danger associated with their misuse, further reducing the risk of developing symptoms of toxic shock syndrome. Currently, this form of TSS, defined as "menstrual" represents about 70% of cases and presents a variable risk depending on the degree of absorbency and the chemical composition of the buffer itself.

Next to the form of toxic shock syndrome associated with the use of internal absorbents, there is a "non-menstrual" form, related to serious infections, also of nosocomial origin. In some circumstances, the bacteria grow rapidly and activate an immune response that triggers the dramatic onset of a combination of symptoms: high fever, diffuse erythematous skin rash, sharp drop in blood pressure, etc. Bacterial exotoxins can cause involvement of other organs in the body and become complicated with a series of eventualities that can induce death. Early diagnosis and appropriate treatment prevent disease progression and possible complications, with a good chance of recovery.


The exact cause of TSS is unknown, but most cases are associated with an infection due to Staphylococcus aureus strains. The toxin most frequently implicated in the pathogenesis of toxic shock syndrome is TSST-1 (toxic shock toxin-1), produced by Staphylococcus. This - together with other types of bacterial toxins, such as the staphylococcal enterotoxin B or C or the pyrogenic exotoxin produced by Streptococcus pyogenes (Group A hemolytic streptococcus β) - belongs to the category of so-called superantigens. These particular molecules are able to directly activate a very high immune response compared to normal antigenic stimulation. The reaction results in the release of large amounts of cytokines and other chemical mediators, which produce fever, rash, tissue lesions and shock.

It is important to consider that the colonization of pathogens participates in the genesis of the toxic shock syndrome, but it is not a sufficient factor to determine the clinical picture of the condition, which always remains a rare occurrence. Staphylococcus aureus is a commensal of human skin and mucous surfaces and as such can normally exist in different districts of the body, without causing infection or disease (colonization). However, individuals who have not developed anti-TSST-1 antibodies (or against other toxins) may develop toxic shock syndrome. Furthermore, Staphylococcus aureus infections can develop as a complication of other localized or systemic infections, such as pneumonia, osteomyelitis (bone infection), sinusitis and skin wounds (such as surgical incisions or burns). Streptococcus pyogenes toxic shock syndrome (STSS) can occur as a secondary infection, such as influenza A, chicken pox or bacterial cellulitis (infections of the skin and underlying tissues).

Risk factors

"Non-menstrual" toxic shock syndrome occurs in men and women of all ages and is usually caused by localized or systemic infections.

Most cases of "menstrual" toxic shock syndrome are associated with the use of internal pads, but the condition is now relatively rare.

The exact etiology of toxic shock syndrome has yet to be defined, but cases have been associated with:

  • Superabsorbent internal pads;
  • Prolonged use of antibiotics;
  • Staphylococcus or streptococcus infections, especially in the presence of cutaneous wounds or surgical incisions, even when the inflammatory reaction seems minor;
  • Some contraceptive methods to be inserted into the vagina: vaginal diaphragm and contraceptive sponge (cylindrical polyurethane sponge soaked in a spermicide, to be inserted into the vagina before sexual intercourse);
  • Skin damage (burns or burns);
  • Gynecological infections and / or puerperal sepsis (severe infection of the uterus, which occurs after childbirth or an abortion).

Use of the pad . Researchers don't know exactly how swabs can cause toxic shock syndrome. Some believe that when superabsorbent pads are left in place for a long time they can become a breeding ground for bacteria. Another theory suggests that the fibers of the internal absorbent can scratch the walls of the vagina, facilitating the entry of bacteria or their toxins into the bloodstream. No evidence was found to support these hypotheses.


The toxic shock syndrome has a very serious clinical course. If staphylococci or streptococci are the cause, the symptoms develop suddenly and worsen rapidly over a short period of time. Generally, in "menstrual" forms, the onset occurs within the 3rd-4th day of the cycle, with a sudden fever, higher than 38.9 ° C. Blood pressure drops to dangerously low levels and is associated with at the onset of vertigo. Other clinical signs then develop rapidly, over the course of a few hours. These may include: chills, vomiting, sore throat, diarrhea and muscle pain. After 1-2 weeks, on the palms of the hands and soles of the feet a typical skin desquamation (similar to the outcome of a sunburn) can occur. In the streptococcal toxic shock syndrome, the wound is painful and gangrene can develop around the infected lesion. When the source is a swab infected with staphylococci, the syndrome may recur, usually within 4 months of the first episode. An important characteristic of TSS is that it has, in fact, a tendency to recur, although - fortunately - each episode tends to be less severe than the first infection. To reduce the risk of re-infection, women who have had the syndrome should not use internal tampons. Recurrences have been reported in approximately 30-40% of cases.

The most frequent clinical signs found in toxic shock syndrome are:

  • Sudden high fever (38.9 ° C or higher);
  • Hypotension (systolic blood pressure <90 mmHg);
  • Coagulopathy, with bleeding problems;
  • Chills;
  • Nausea, vomiting and / or diarrhea;
  • Widespread rashes on the body similar to erythema, in particular on the trunk, face, palms of the hands and soles of the feet;
  • Confusion and disorientation;
  • Abdominal pain and vaginal discharge;
  • Muscle pain or weakness;
  • Redness of eyes, throat and vagina;
  • Headache or dizziness;
  • Swelling of the face and eyelids.

Initial symptoms may improve, but the disease may continue to progress and cause damage to many organs. Several organs like kidneys, liver, heart and lungs may not work properly or develop organ failure (inability to cope with the body's demands).

The possible serious complications of TSS include:

  • Breathing difficulties;
  • Loss of consciousness;
  • Rhabdomyolysis;
  • Gangrene;
  • Pancreatitis;
  • Cardiomyopathy;
  • Acute liver failure;
  • Encephalopathy and cerebral edema;
  • Thrombocytopenia and marrow suppression;
  • Disseminated intravascular coagulopathy (DIC);
  • Metabolic acidosis and electrolyte disturbances.

When streptococci are involved, the syndrome can be fatal up to 70% of cases, while if the infection is due to staphylococci, about 5% of patients may die if the form is "menstrual" and 15% if not is. If people are treated shortly, recovery is usually complete.

When to consult a doctor. If a sudden fever develops and one or more of the other symptoms listed above, it is extremely unlikely that the patient will present TSS. However, these clinical signs should never be ignored and it would be advisable to contact your doctor immediately to ascertain your condition, listing the symptoms and timing with which they occurred. If a tampon is in the vaginal area, remove it immediately. Also, tell your doctor if you have used internal sanitary napkins or if you have developed a skin infection, such as a boil or a bubble that has become infected.


Toxic shock syndrome is diagnosed by identifying typical symptoms, performed by a complete physical exam (which includes a pelvic exam in women), through blood analysis, to look for the presence of a staph infection or streptococcus, and through the evaluation of renal and hepatic function. Blood cultures are positive in 5-15% of cases of toxic shock syndrome. Urinalysis can show microscopic hematuria and myoglobinuria. The doctor may also perform a pharyngeal (or vaginal) swab when there is a clinical suspicion of an outbreak of infection. Other tests can be performed to rule out other medical conditions.

The definition of toxic shock syndrome requires the following clinical criteria:

  1. temperature> 38.9 ° C;
  2. low blood pressure (with fainting or dizziness in an upright position);
  3. diffuse erythematous rash;
  4. skin desquamation, 1-2 weeks after the onset of the disease;
  5. multisystem involvement (evidence of 3 or more organs affected by infection):
    • Gastrointestinal: vomiting and / or diarrhea;
    • Muscular: severe muscle pain and increased CPK (creatine phosphokinase);
    • Hepatic: decreased liver function;
    • Renal: increase in blood urea, urea and creatinine values;
    • Hematologic: thrombocytopenia (also evident from the appearance of bruises);
    • Central nervous system: disorientation or disturbance of consciousness;
    • Mucous: redness of eyes, mouth and vagina, due to increased blood flow in these areas.


The specific treatment for toxic streptococcus and staphylococcal shock syndrome is established by the physician based on:

  • Age, general health conditions and the patient's medical history;
  • Infectious agent;
  • Extent of the disease;
  • Expectations for the course of the disease.

There are two important goals in the treatment of toxic shock syndrome: fighting the infection and supporting the functions of the organs that have been affected, to reverse the deterioration process. The patient needs immediate hospitalization in an intensive care unit. Most people respond to treatment within a couple of days, but the condition can take several weeks to restore good health.

Treatment of infection

The infection can be managed with a combination of antibiotics, which are administered intravenously. Antibiotics do not cure TSS, but are essential to manage the condition. In severe cases, immunoglobulins may also be given: this therapy may be indicated to neutralize the toxins produced by the bacteria and to support the antibody defense.


In the event of hypotension, drugs are administered to stabilize blood pressure.

Life support

To support breathing, extra oxygen can be provided to the patient. Supportive treatment also includes the intravenous administration of fluids to prevent dehydration and organ damage.


The toxins produced by the staphylococcal or streptococcus bacteria, associated with hypotension, can cause kidney failure. If the kidneys stop working, a dialysis machine can be used to filter the blood.

Cleaning the infected tissue

If the toxins have damaged parts of the skin tissue or other ends of the body such as the fingers or toes, the infected site will have to undergo an irrigation procedure. In very serious cases, surgical cleaning of the infected wound or amputation of one end of the body may be necessary if gangrene has developed.

Prevention of toxic shock syndrome

Women who use internal pads can take various precautionary measures:

  • Avoid using internal pads when the flow is very light;
  • Alternate the use of external absorbents and tampons;
  • Change pads frequently during the day, at least every six hours;
  • Keep the package containing the internal sanitary napkins in a clean and dry place;
  • Wash your hands with soap and water before and after inserting a swab;
  • Use a pad with a lower absorbing power, if you find irritation or difficulty in removing it.
  • In the event of a previous episode of toxic shock syndrome or a serious staphylococcal or streptococcus infection, do not use internal absorbents or contraception to be introduced into the vagina

Finally, the fundamental strategy to avoid toxic shock syndrome involves rapid and complete wound care, to prevent any infections.