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Toxic Shock Syndrome

Dr. Nabi Darya Vali (AIIMS)MBBS

June 24, 2020

June 24, 2020

Toxic Shock Syndrome
Toxic Shock Syndrome

Toxic shock syndrome is a rare but life-threatening infection. It presents as a cluster of symptoms that involve different systems of the body, all at once. Toxic shock syndrome was first reported in a group of children in 1978. In the early 1980s, there were several reports of toxic shock syndrome among women who used superabsorbent tampons during their periods.

Toxic shock syndrome occurs due to the entry of bacteria into the bloodstream through a wound or an injury. Toxic shock syndrome is also associated with the use of tampons in women. However, it can affect anyone of any age, including men and children. Around 50% of the cases of toxic shock syndrome are non-menstrual.

In toxic shock syndrome, bacteria enter the bloodstream and release toxins which spread to all the organs. This is an acute-onset disease (it occurs suddenly) where the patient shows symptoms of fever, low blood pressure, sunburn-like rash on the body and sometimes it may result in end-organ damage. There are three bacteria—Staphylococcus aureus, Streptococcus pyogenes and Clostridium sordellii—which are mostly responsible for toxic shock syndrome. 

The treatment may involve removal of any tampon from the vagina of the affected women, administration of fluids and electrolytes (fluid therapy), delivering antibiotics to kill the microorganisms and preventing the spread of the toxin in the body.

Symptoms of toxic shock syndrome

The symptoms of toxic shock syndrome usually appear suddenly.

The symptoms may vary depending on the type of bacteria that are producing the toxins.

The most common symptoms of staphylococcal toxic shock syndrome are:

  • High-grade fever (higher than 102°F) with chills
  • Fatigue
  • Headache
  • Red skin rashes covering almost all parts of the body
  • Skin starts shedding from the palms and soles one to two weeks after the onset of other symptoms
  • Muscle pain
  • Nausea and vomiting
  • Diarrhoea
  • Redness of eyes, mouth and vagina
  • Disorientation and state of confusion
  • Reduced frequency of urination
  • Cloudy urine indicating the presence of some cells or microorganisms in it 
  • Reduced liver function 
  • Easily bruised skin indicating low blood platelet count in the body

The most common symptoms of streptococcal toxic shock syndrome are:

  • Difficulty breathing
  • Pain in the abdomen
  • Skin starts shedding from the palms and soles (this may or may not occur)
  • Red rashes covering almost all parts of the body
  • Severely low blood pressure leading to dizziness
  • Bruised skin indicating low blood platelet count in the body
  • Decreased kidney function
  • Signs of liver impairment—such as swelling of legs and ankles, yellowish pigmentation of the skin and eyes—may be seen
  • Shock

The most common symptoms of C. sordellii toxic shock syndrome are:

  • Flu like symptoms such as muscle pain, cough and headache but no fever.
  • Nausea and vomiting
  • Fatigue 
  • Pain in the abdomen
  • Swelling due to fluid buildup in the body
  • Low blood pressure
  • Rapid heart rate (Tachycardia)

Causes of toxic shock syndrome

One of these three bacteria can cause toxic shock syndrome:

  • Staphylococcus aureus: Staphylococcus aureus (or S. aureus) is normally present in the human body but the immune system forms antibodies against it, thus it generally does not harm us. However, people lacking antibodies against this bacteria may get this infection. S. aureus infections can also develop when the bacteria penetrates into skin wounds, burns or surgical site. This bacteria can also cause infection in people suffering from pneumonia, sinusitis (inflammation of the sinus) or osteomyelitis (infection in the bone).
  • Streptococcus pyogenes: Streptococcus pyogenes (or S. pyogenes) may occur as a secondary infection and is mostly seen in people with chickenpox, diabetes,  chronic lung disease, heart disease or people with weak immunity.
  • Clostridium sordellii: Clostridium sordellii (or C. sordellii) is normally present in the vagina but does not cause any infection. The bacteria get access to the uterus during menstruation, childbirth, or abortion.

How to prevent toxic shock syndrome?

Women can prevent the occurrence of toxic shock syndrome by taking care of the following things:

  • Make sure that you change your tampon once every four to eight hours.
  • Do not insert more than one tampon in your vagina.
  • Do not use super-absorbent tampons. Try using the lowest absorbency one.
  • Wash your hands with soap and water before and after using a tampon.
  • Unwrap the tampon only when you are going to use it immediately 
  • Insert and remove the tampons gently. 
  • Do not use applicator tampons as they might scrape the walls of the vagina.
  • During the night, try using sanitary pads instead of tampons.
  • Do not use tampons if you do not have periods.
  • Maintain personal hygiene during your periods.
  • Try avoiding tampons when your flow is minimal. You can use pads or panty liners during those days.
  • Read the user manual carefully before using the female barrier contraception.

Toxic shock syndrome diagnosis

Doctors may perform a vaginal examination to determine the cause of your symptoms and also to get tissue cultures.

There are no specific tests for toxic shock syndrome. So, the doctor may perform the following tests to make a diagnosis:

  • Blood cultures: This test is done to find and identify the disease-causing microorganisms.
  • Complete blood count (CBC): A CBC would reveal any inflammatory cells present in the blood along with blood clotting and bleeding times, white blood cell counts and electrolytes.
  • Urine test: A urine examination would be done to look for the presence of bacteria in the urine.
  • Lumbar puncture: Lumbar puncture, also known as the spinal tap, is a procedure in which a small amount of spinal fluid is taken by inserting a needle in the spine. This fluid is used to check for bacterial infection.

Treatment for toxic shock syndrome

If a person is suspected of toxic shock syndrome, they must be given immediate medical help as this condition can be life-threatening. Any foreign body, including tampons, diaphragms and others, should be removed at once. 

The first step towards treatment is finding the site of decontamination, followed by reinspection and irrigation of surgical wounds (even if they are healing properly). The doctors would also irrigate the sites which are prone to get infected by the bacteria such as sinuses and vagina. Once the site of infection is found, the doctors would repeatedly debride the devitalized tissues (remove affected tissue).

The rest of the treatment would involve the following: 

  • Intravenous administration of antibiotics: Antibiotics, given through the veins, would eradicate the bacteria and would also prevent recurrence of the condition. In cases where the culture results of toxic shock syndrome are pending, doctors may prescribe clindamycin or linezolid along with vancomycin or daptomycin as they help in suppressing the toxin production.
  • If the culture reports are available, the following drugs are given on the basis of the causative agent:
    • For Streptococci bacteria, the patient is given clindamycin along with a beta-lactam.
    • For methicillin-susceptible S. aureus (MSSA) bacteria, the patient is given clindamycin along with oxacillin or nafcillin.
    • For methicillin-resistant Staphylococcus aureus (MRSA) bacteria, the patient is given vancomycin or daptomycin along with clindamycin or linezolid.
  • The patient is given plenty of electrolytes and fluids intravenously to treat hypovolemia (low blood volume), hypotension (low blood pressure) and shock. This would also prevent organ damage.
  • Some people may require a blood transfusion, depending on their condition.
  • The patient may be given supplemental oxygen or mechanical ventilation (ventilator) if they present with breathing difficulties. (Read more: Oxygen therapy)
  • Dialysis can be required in the patients who would develop kidney failure due to toxic shock syndrome.


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