Toxic Shock Syndrome: More Than a ‘Tampon Disease’

TSS was first discovered in 1978. Although the infection is commonly known as the ‘tampon disease,” it was first identified in boys and non-menstruating girls. However, 65-75% of TSS cases are related to menstruation. Initially, the Centers for Disease Control and Prevention (CDC) referred to it as ‘Staphylococcus Toxic Shock Syndrome’ because they suspected that the Staphylococcus aureus bacteria was responsible.

In 1980, Dr. Andy Dean reported 9 cases of a disease in women in Minnesota and Wisconsin to the CDC. All the women had an infection during the onset of or during their menstrual cycle. The CDC connected the symptoms to similar ones reported in 1978. At this time, they also discovered the link between infections and the use of superabsorbent tampons. After this discovery, there were widespread awareness campaigns and changes to the way tampons were made.

At the time, certain tampons were made with polyester foam or carboxymethylcellulose (CMC), which increased the risk of bacterial infection. In particular, they were prime growing conditions for S.aureus, which then produced the toxin responsible for TSS.

In 1981, scientists found a specific type strain of Staphylococcus aureus bacteria responsible for symptoms of TSS. They named it toxic shock syndrome toxin-1 (TSS-1). While menstruating women were most affected, TSS can also occur in men, children, and non-menstruating women (like post-menopausal women).

Tampon manufacturers have changed the way they make tampons, and the risk of TSS has decreased significantly. However, TSS warnings continue to be included in tampon boxes even today.

The incidence of TSS is quite low. In the United States, TSS incidence is 0.8 to 3.4 per 100,000. The incidence is higher in winter.

Notable outbreaks

• 1970-1982 in the United States: 1,660 cases with 88 deaths. 92% of cases during this time were discovered in females who were menstruating.
  • 1980-1981: Rely tampon outbreak: The tampon brand Rely, made by Proctor & Gamble, was a high-absorbency tampon made of polyester foam. Many women who used Rely tampons were affected by TSS during this time.
• 1996-2019: 4 cases of neonatal TSS-like infections were reported in France.

Outbreak data is from GIDEON, the world’s leading infectious diseases database. Subscribe to GIDEON to access more data on TSS and other infectious diseases. 

Direct transmission is not possible with TSS. This means TSS cannot be spread from person to person.

The risk factors that increase the chances of developing toxic shock syndrome include:

1. Skin Wounds: Bacteria that cause TSS live on our skin, in our nose, throats, and other regions, and that is normal. However, certain instances can trigger greater growth. and lead the bacteria to produce the TSS toxin. For example, cuts, burns, surgical incisions, and other injuries create openings where the TSS bacteria can infiltrate your system and begin to release toxins into the bloodstream.
2. Super-absorbent Tampons: Menstrual-associated TSS is the risk of using tampons that are super absorbent and were left in place for extended periods.
3. Viral Infections: A viral infection such as the flu or chickenpox can weaken your immune system, making it easier for bacteria to enter and cause TSS. Please note that the risk of TSS due to viral infections is rare.

The TSS bacteria can enter the human body through many ways, including a compromised skin barrier, and mucous membranes like the nose, throat, and genitals. The TSS bacteria can also enter the body during some medical procedures and the use of certain medical devices. For example, in some surgeries, gauze and other materials are inserted into the nose to control bleeding. If this gauze is not sterile, the TSS bacteria can begin to grow.

Once inside the body, TSS bacteria can produce toxins like TSS-1 and release them into the bloodstream. The body’s immune system reacts to the toxins, causing symptoms like fever and rashes. In severe cases, it can cause organ failure and can be life-threatening.

TSS symptoms often appear suddenly and may include:

• High fever
• Chills
• Muscle pain (Myalgia)
• Nausea and vomiting

Symptoms can progress rapidly, and infected individuals can experience:

• Sepsis
• Low blood pressure
• Faster heart rate (tachycardia)
• Signs of organ failure (kidney, lung, liver, blood)

There is no diagnostic test to detect TSS specifically. However, blood and urine analysis may be required to test for a staphylococcus infection. Additionally, tissue culture samples from suspected infection sites (like vagina, wounds, or throat) may be used for a laboratory culture test to confirm the presence of TSS-causing bacteria.

If the medical professional suspects that organs may be affected, scans like CT scans, X-rays, and even a lumbar puncture may be needed.

The three major criteria for diagnosing toxic shock syndrome include:

1. Sudden onset of high fever (>38.9°C or >102°F)
2. A diffuse sunburn-like rash followed by skin peeling on palms and soles within one to two weeks after the onset of illness
3. Hypotension (low blood pressure)
4. Additionally, at least three organ systems must be involved for a diagnosis.

Key Takeaway: To diagnose toxic shock syndrome, doctors evaluate the patient’s medical history and perform physical examinations. Laboratory tests such as blood tests, cultures, and lumbar punctures are used to identify TSS. Imaging studies like X-rays or CT scans may be necessary in cases of multiple organ failure caused by TSS.

Treating TSS usually involves immediate hospitalization and the use of antibiotics to combat infection. If blood pressure is low, medication can be provided. If there is dehydration, intravenous drugs will be administered. If there are breathing difficulties, oxygen therapy may be offered. Dialysis can help address kidney failure.

As of February 2023, a vaccine to help prevent Staphylococcal-induced toxic shock syndrome (TSS) completed a Phase 2 study. The vaccine, called TSST-1, was discovered to be safe and effective and provides immunity against the bacteria for two years. Plans for a Phase 3 study are underway.

To reduce the risk of developing toxic shock syndrome, it is crucial to adopt good hygiene habits and take appropriate precautions. Adopting the right measures can help to minimize the risk of contracting this bacterial infection.

• Hand hygiene: Maintaining proper hand hygiene is essential in preventing the spread of infectious diseases like toxic shock syndrome. Thoroughly washing hands with soap and water for at least 20 seconds helps remove harmful bacteria such as Staphylococcus aureus and Streptococcus pyogenes. This practice is especially important when handling open wounds or skin infections, which may serve as entry points for these bacteria into the body. For more information on effective handwashing techniques, visit the CDC’s guide on handwashing.
• Choose sanitary pads over tampons: Using sanitary pads instead of tampons or pads at night can help lower the risk of getting TSS during a menstrual cycle. 
• Change tampons regularly: Avoid the use of superabsorbent tampons and change tampons every four to eight hours. Tampons should not be used unless the individual is menstruating.
• Maintaining sterility of surgical instruments and medical devices: Keeping surgical equipment and medical devices (including vaginal contraceptives like diaphragms) clean and sterile is important to prevent the risk of TSS.

Toxic shock syndrome is a rare but serious condition that can lead to multiple organ failure and even death. It is caused by bacterial infections, with Staphylococcus aureus being the infecting pathogen. Early warning signs include fever, rash resembling sunburn, and low blood pressure. If you develop TSS, it is important to contact a doctor immediately.

Diagnosis involves blood tests and imaging studies to identify complications. Treatment options for TSS include intravenous fluids, antibiotics, and medications to control blood pressure. In severe cases, patients may require admission to an intensive care unit.

Prevention strategies involve alternatives to tampon use during menstruation and proper wound care hygiene. Super-absorbent tampons have been associated with an increased risk of staphylococcal TSS, so it’s important to use the lowest absorbency tampon possible and change it frequently. Wound infections can also lead to TSS, so it’s important to keep any cuts or wounds clean and covered.

Streptococcal TSS can occur as a complication of a strep infection, including strep throat. Paeniclostridium sordellii is another bacterium that can cause TSS, often associated with childbirth or gynecologic surgery.

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