Toxic Shock Syndrome, or TSS, is a rare but potentially lethal disease characterized by its sudden onset of symptoms which can accumulate to blood poisoning (shock).2 It is caused by a bacterium that, under normal conditions, are regularly present on skin, in mucous membranes, and genital regions.1 Many people assume TSS is caused by the wearing of tampons during menstruation and that it occurs only in women. TSS is a damaging disease if left untreated and can occur in both sexes and at any age.
The term "Toxic Shock Syndrome" was coined by a J. Todd and associates when he first reported the symptoms in seven children, ages eight to seventeen in 1978.5 The name refers to the toxin occasionally developed by the bacterium Staphylococcus aureus and is called Toxic Shock Syndrome Toxin-1 (TSST-1).5 This toxin has the ability to cause shock in the patient if left untreated. 5 In 1979 fifty-five reported cases occurred and in 1980 the Centers for Disease Control published its first MMWR explaining its emergence and diagnosis to physicians.4 As the number of reported cases increased, a trend between tampon use and TSS was noticed as ninety percent were young menstruating women.6 Belief that superabsorbancy tampons initiated the growth of S. aureus led manufacturers to lower the absorbency and composition of tampons. Substantial decline soon followed and, by 1996, there were less than 100 reported cases and only about half of them were menstruating women. 6
As mentioned earlier, the etiological agent for TSS is Staphylococcus aureus, which are composed of Gram-positive cocci usually arranged in grape-like clusters and sometimes chains or pairs. It is normally present on skin, mucous membranes, in the nose, groin, armpit, and vagina.1 TSS is acute but non-contagious.1 It is transmitted by infection of an S. aureus strain that produces toxins.2 Tampons, contraceptive devices (caps, sponges, and diaphrams), and skin wounds from injury or surgery are believed to increase the chances of human colonization.7 Tampons are the most noteworthy contributing factor and are believed to cause a warm, moist environment for S. aureus growth.6 Two other theories may be that tampons block the bacteria in the vagina allowing it to breed and produce toxins, and small cuts in the vagina caused by tampons may provide a portal of entry for bacteria and/or their toxins to enter the bloodstream.7
Exotoxins produced by S. aureus are responsible for the onset of symptoms and account as virulence factors for the development of TSS. At certain times of bacterial growth, these exotoxins, which are composed of proteinaceous compounds, are secreted.2 The most common TSS toxins are TSST-1 (Toxic Shock Syndrome Toxin-1) and staphylococcal enterotoxin B (SEB).2 Other toxins include enterotoxins A, C, D, and E. TSST-1 accounts for about 75% of cases and it suppresses neutrophil chemotaxis, induces suppressor T-cells to function, and blocks the reticuloendothelial system.5
The signs and symptoms of TSS develop rapidly and suddenly,7 and initial symptoms often resemble the flu.2 They include fever (102°F/40°C or higher), headaches, sore throat, vomiting, diarrhea, dizziness/lightheadedness/fainting, cramping, confusion/disorientation, sunburn-like rash on soles of feet and palms of hands (later resulting in peeling of the skin).7 If TSS is not properly treated a sudden drop in blood pressure will cause shock.7
Apart from visible signs and symptoms, to identify S. aureus and determine if TSS is indeed the case when diagnosing a patient, samples will be taken from the blood, urine, and (if female) cervical smear samples.3 If S. aureus is present, when grown in culture, it will form domed, glistening white or golden colonies on blood agar and will be positive when tested for catalase and coagulase.12 To confirm TSS, a doctor will first verify if female patient was menstruating, is postpartum and/or using barrier contraceptives. Burn and postoperative patients, male and female, are also considered in the diagnosis.2 If a lab test is positive for TSS it will contain evidence of leukocytosis, elevated prothrombin time, hypoalbuminemia, hypoalcemia, and pyuria.2 Other lab findings will reveal blood urea nitrogen, serum creatine, bilirulin, creatine phosphokinase levels, and white blood cell counts with marked left shifts.4
TSS is treated with antibiotics and patient must be hospitalized in order to control and treat symptoms. Hospitalization ensures patient receives intravenous fluids, blood pressure support, medication for shock, dialysis (if kidney dysfunction occurs), and intravenous immunoglobulin. 8, 9 Respirators are used if respiratory distress occurs, and cleaning/draining the infected site by removal of tampon or contraceptive device or irrigation and removal of packing of wounds are also included.10 Some antibiotics used to kill S. aureus of severe infections include gentamicin, fusidic acid, erythromycin, tetracycline, chloramphenicol, and clindamycin.12 For penicillin-allergic patients, flucloxacillin is administered, and vancomycin and teicoplanin (both given parentally) for methicillin-resistant strains of S. aureus.12
Even though TSS is rare, preventative measures still need to be practiced to ensure safety. For women using tampons, it is imperative that careful attention be applied and instructions be read.8 Selecting low absorbency tampons, alternating tampons with sanitary napkins, and using sanitary napkins at night reduces risk. Seeking medical help at first notice of symptoms ensures better treatment and cure.8 Because S. aureus is becoming more resistant to antibiotics, Robert Williams, professor of chemistry at Colorado State University, and graduate students are currently studying a drug called TAN 1057 to treat drug-resistant S. aureus.11 TAN 1057 was developed by a pharmaceutical company in Japan.11
In conclusion, TSS accounts for one in every 100,000 menstruating women1 and is based on three criteria: 1. Colonization of S. aureus, 2. Development of toxins (TSST-1), and 3. Toxins have a route of entry into the circulatory system.5 TSS is severe but preventable and depends, for the most part, on individuals using proper hygiene.
Online References
1. "Key Facts About TSS," (no available date), www.toxicshock.org.au/ accessed April 29, 2002
2. Deresiewicz, Robert L. "Toxic Shock Syndrome: A Health Profession's Guide" (no date available) www.toxic-shock.com, accessed April 20, 2002
3. "Toxic Shock Syndrome: Serious but Preventable," 2000, www.womens-health.com/health_center/gynecology/gyn_md_tss.html, accessed April 29, 2002
4. "Epidemiological Notes and Reports Toxic Shock Syndrome&emdash;United States, June 6, 1997, www.cdc.gov/mmwr/preview/mmwr/0047818.htm
5. Herzer, Christopher M., "Toxic Shock Syndrome: Broadening the Differential Diagnosis," Feb. 14, 2001, www.familypractice.com/journal/abfpjournal_frame.htm, accessed May 1, 2002
6. Rutheford, Kim and Joel Klein, "Toxic Shock Syndrome," Feb 2002, www.kidshealth.org/parent/infections.htm, accessed May 1, 2002
7. "Toxic Shock Syndrome," 1999, www.stjohns.org/HTL/circulatory/20904.htm, accessed May 1, 2002
8. "What is Toxic Shock Syndrome (TSS)?" June 2001, www.crha-health.ab.ca.hlthconn/items/tss.htm, accessed May 1, 2002
9. Hurtado, Rocio, "Toxic Shock Syndrome," Sept. 1, 2001 www.nlm.nin.gov/medlineplus/ency/article/000653, accessed May 7, 2002
10. "Toxic Shock Syndrome (TSS)," June 2001 www.montgomerygeneral.org/medsource/wo, accessed May 7, 2002
11. "Overcoming Resistance to Therapeutic Drugs," Oct. 13, 2000, www.colostate.edu/Depts/NatSci/html/drugs.html, accessed May 7, 2002
12. Pallen, Mark, "The Staphylococci," March 1998, www.medmicro.mds.qmv.ac.uk, accessed May 7, 2002