Toxic Shock Syndrome

Toxic shock syndrome (TSS) is a rare but potentially fatal disease caused by toxins produced by two types of bacteria. It is most commonly associated with tampon use but has also been linked to the use of contraceptive diaphragms, wound infections, complications following surgery, and infection resulting from childbirth or abortion.

TSS is caused by the release of toxins from the strains of bacteria, Staphylococcus aureus, and less commonly, Streptococcus pyogenes. Infections caused by the latter strain are called streptococcal toxic shocklike syndrome (σTSS), and although it is a similar syndrome to TSS, it is not identical. The median incubation period of infection of TSS is approximately 2 days.

Symptoms of TSS infection can develop very suddenly and typically include fever, nausea, diarrhea, vomiting, and muscle aches. A sunburn-like rash on the palms and the soles is typically present during the acute phase and peels within a few weeks. More serious complications include hypotension and sometimes even multiorgan failure. Infection is subsequently diagnosed with tests that may include blood and urine tests. On confirmation of diagnosis, treatment typically involves the administration of antibiotics, and in general, the patient recovers in approximately 7 to 10 days. In more serious cases, treatment may include hospitalization and administration of intravenous fluids.

TSS was first described in 1978 in the United States in an outbreak of seven young children. However, it became more commonly known in 1980 as a result of an epidemic associated with the prolonged use of highly absorbent tampons in menstruating, healthy, [Page 1043]young women. This association was due to the efficiency of superabsorbent tampons in absorbing magnesium, low levels of which are associated with increased production of TSS-associated toxin, TSS Toxin 1. After this initial epidemic, TSS became a nationally reportable disease in the United States in 1980.

Following this epidemic, the number of cases of TSS has declined significantly. Influencing factors might include changes that were made in tampon production that led to a decrease in tampon absorbency, greater knowledge of TSS among women and physicians, and the standardized labeling required by the U.S. Food and Drug Administration. Specifically, superabsorbent tampons were removed from the market after the outbreak in 1980. In 1979, before these tampons were removed from the market, menstrual TSS accounted for approximately 90% of all cases. By 1996, it accounted for approximately half of all cases. The annual incidence rate when the last surveillance was done in 1986 was approximately 1 per 100,000 women. It is fatal in about 5% of all cases.

An additional change in the epidemiology of TSS since this time is the relative increase in the proportion of nonmenstrual cases, particularly those reported following surgical procedures. This could be due to an increase in outpatient procedures and therefore increased opportunity for infection. Preventive efforts focus on patient education about early signs and symptoms and risk factors for TSS.