Toxic Shock Syndrome (TSS)

What causes toxic shock syndrome

Some strains of Staphylococcus aureus and group A Streptococcus (Streptococcus pyogenes) produce toxins that act as superantigens. These overstimulate the immune system, triggering a massive release of inflammatory chemicals that dilate blood vessels, make them leaky and cause shock and organ damage. It resembles septic shock but is driven by toxins rather than bacteria spreading through the blood.

Staphylococcal TSS

• menstrual: associated with tampons (especially high-absorbency or worn too long), menstrual cups, sponges and diaphragms
• non-menstrual: surgical wounds (see wound infection), burns, nasal packing after nose surgery or nosebleeds, skin infections, abscesses, childbirth, and after flu

Streptococcal TSS

• often follows skin or soft tissue infections such as cellulitis, including necrotizing fasciitis
• after chickenpox, surgery, childbirth or minor injuries
• more common in older adults, people with diabetes, alcohol use disorder or injected drug use
• usually more deadly than staphylococcal TSS

Symptoms

Symptoms develop suddenly, often within 2 to 3 days of the trigger:

• high fever, usually over 38.9 °C (102 °F)
• low blood pressure: dizziness, lightheadedness, fainting
• a diffuse red, sunburn-like rash, especially on the palms and soles
• vomiting and diarrhea
• severe muscle aches
• red eyes, mouth and throat
• confusion or agitation
• reduced urine
• peeling of skin on the palms and soles 1 to 2 weeks later (staph TSS)
• in strep TSS: severe pain at the site of infection, often before skin changes appear

Diagnosis

TSS is diagnosed by its clinical features using CDC case definitions. Tests include:

• blood tests: blood count, kidney and liver function, clotting, creatine kinase, platelets
• blood cultures (often positive in strep TSS, usually negative in staph TSS)
• cultures of the vagina, wound or nasal packing
• imaging and surgical exploration if a deep infection is suspected

Treatment

TSS is treated in the hospital, often in intensive care:

• remove the source: tampons, cups, packing, and drain or surgically clean infected wounds
• intravenous fluids and medicines to support blood pressure
• antibiotics: a combination that includes clindamycin (which suppresses toxin production) plus another antibiotic such as vancomycin or a penicillin, adjusted to culture results
• intravenous immunoglobulin (IVIG) in severe cases, especially strep TSS
• organ support: oxygen, ventilation, dialysis as needed

Complications

• kidney failure
• liver failure
• heart failure and arrhythmias
• acute respiratory distress syndrome
• blood clotting abnormalities
• loss of fingers, toes or limbs from tissue damage
• death

Prevention

Menstrual products

• use the lowest absorbency tampon needed for your flow
• change tampons every 4 to 8 hours, and never leave one in longer than 8 hours
• alternate tampons with pads, especially overnight
• empty and clean menstrual cups as directed (generally at least every 12 hours)
• wash hands before inserting or removing products
• do not use tampons if you have had TSS before, unless your doctor says it is safe

Wounds and other sources

• keep wounds clean and covered, and seek care for signs of infection
• follow instructions for nasal packing removal
• treat skin infections promptly

Frequently asked questions

What are the first signs of toxic shock syndrome?

Early signs include a sudden high fever, a sunburn-like rash, vomiting or diarrhea, muscle aches, dizziness or fainting, and confusion. Symptoms come on quickly. If you have these while using a tampon or after surgery or a wound, remove the tampon and seek emergency care.

Can you get toxic shock syndrome from a tampon?

Yes, although it is rare today. The risk is linked to high-absorbency tampons and leaving them in too long. Using the lowest absorbency needed and changing tampons every 4 to 8 hours greatly reduces the risk.

Can menstrual cups cause toxic shock syndrome?

Rarely, yes. A few cases have been reported with menstrual cups. Wash your hands before handling the cup, empty and clean it as the manufacturer directs, and sterilize it between cycles.

Can men get toxic shock syndrome?

Yes. About half of staphylococcal TSS cases today are not linked to menstruation. TSS can follow skin infections, burns, surgery, nasal packing and other wounds in anyone, including men and children.

Is toxic shock syndrome curable?

Yes, with prompt treatment most people recover, especially from staphylococcal TSS. Streptococcal TSS is more dangerous. Fast removal of the source, antibiotics and intensive care support are critical for survival.