What is Toxic Shock Syndrome?
Toxic shock syndrome (TSS) is a sudden and serious illness that includes symptoms like fever, low blood pressure, a rash that looks like sunburn, and damage to certain organs in the body. TSS was often linked to the use of very absorbent tampons in women on their period. These tampons have since been removed from the market. However, it’s still important to watch out for TSS in cases that aren’t related to periods. In the United States, TSS is thought to affect between 0.8 to 3.4 people out of every 100,000.
Spotting the signs of TSS early on and starting treatment with antibiotics as soon as possible are crucial steps in improving the chances of recovery and lowering the risk of death from the illness.
What Causes Toxic Shock Syndrome?
Toxic Shock Syndrome (TSS) is a serious disease typically caused by a harmful type of bacteria called Staphylococcus aureus or Group A Strep (Streptococcus pyogenes). These bacteria release harmful toxins, or ‘superantigens’, which can lead to TSS. Even though high-absorbency tampons aren’t used as much, TSS often occurs during menstruation.
But TSS doesn’t only happen around menstruation. It can show up in other situations too. These include soft tissue infections like infections in the skin or muscle, infections after surgery, burns, foreign objects left inside the body like nasal packing, and infection around a dialysis catheter which is a tube used for kidney treatment.
When TSS is caused by Staphylococcus aureus, it’s often because of a localized infection like an abscess (a collection of pus). On the other hand, when caused by Streptococcus pyogenes, TSS can occur due to bacteria in the blood, necrotizing fasciitis (a severe infection that destroys skin, fat, and the tissue covering the muscles), or cellulitis (a common skin infection).
Risk Factors and Frequency for Toxic Shock Syndrome
Toxic shock syndrome (TSS), which can occur during menstrual and non-menstrual periods, is estimated to affect 0.8 to 3.4 people per 100,000 in the United States. The rates are typically higher in winter and more widespread in developing countries. Infants and the elderly are most at risk for developing an invasive Group A Strep infection; this infection is a serious condition often linked to TSS. However, it’s worth noting that between one fifth and one third of these infections happen in people who don’t have any known risk factors. The skin is usually the main source and risk factor for severe infection.
- Menstrual and non-menstrual toxic shock syndrome impacts around 0.8 to 3.4 per 100,000 people in the US.
- Infection rates are typically higher in winter and more common in developing countries.
- Infants and elderly people are at greater risk for developing a severe related infection, invasive Group A Strep.
- Between one fifth and one third of these severe infections occur in people with no known risk factors.
- The most common source and risk factor for severe infection is the skin.
Signs and Symptoms of Toxic Shock Syndrome
When someone has Toxic Shock Syndrome (TSS), they typically get hit quickly with symptoms including a high fever, a rash, and low blood pressure. Before these symptoms show up, they may experience a period where they have other signs, such as feeling feverish and chilled, feeling nauseous and vomiting, having aching muscles, a headache, or having a sore throat or trouble swallowing. After these symptoms, the illness progresses to a severe condition known as sepsis and starts effecting body organs. Using superabsorbent tampons, having nasal packing, recent surgery-related wound infections, recent flu virus, or having a weak immune system are things that can increase your risk for TSS.
The Center for Disease Control and Prevention (CDC) says that to diagnose TSS, a person would need to have a fever, rash, low blood pressure, and symptoms showing that multiple body organs are being affected. The rash usually spreads all over the body and initially may be brief and mostly appear on the chest. The rash will then typically peel after one to two weeks. There may be other signs too, like a red, bumpy tongue or open sores in the vagina or on the eye lining. Also, people with TSS may become disoriented or seem mentally “off” without having other symptoms that could explain why.
According to the CDC, Streptococcal Toxic Shock Syndrome, a type of TSS, has specific criteria:
- Low blood pressure, with specifics given for adults and children under the age of 16.
- Failure of two or more body organs, which could include:
- Problems with kidney function
- Issues with blood clotting or platelet levels
- Abnormal liver function indicators
- Symptoms of Acute Respiratory Distress Syndrome
- Rash that can peel
- Soft tissue death, including specific conditions or gangrene
Additionally, group A Streptococcus must be found during lab testing for Streptococcal Toxic Shock Syndrome to be considered.
Then doctors will classify the case as probably this type of TSS if the symptoms match and no other cause is found, with group A Streptococcus found in non-sterile locations. The case gets confirmed if the group A Streptococcus is found in sterile body fluids such as blood, brain and spine fluid, joint fluid, fluid in the chest, or heart sac fluid.
Testing for Toxic Shock Syndrome
Toxic shock syndrome (TSS), a severe illness, isn’t easily identified by a specific lab test. However, a complete blood count (CBC), a standard medical test, could reveal some clues. In this test, the number of different types of cells in your blood, like red blood cells and white blood cells is counted. Unusual findings, like an abnormally high (leukocytosis) or low (leukopenia) count of white blood cells or an increase in a certain type of immature white blood cells, known as bandemia, are common in TSS.
Additionally, doctors may check the health of various body systems or organs. This involves blood tests, including a CBC, a comprehensive metabolic panel (CMP), a creatine kinase (CK) test, and clotting tests. These are done to check for signs that meet the medical definition of TSS established by the Centers for Disease Control and Prevention (CDC).
According to the CDC’s definition, signs of multiple body systems or organs being affected could include symptoms like vomiting and diarrhea, muscle pain, high levels of an enzyme called creatine phosphokinase (CPK), abnormalities in mucous membranes (like your mouth or eyes), elevated levels of blood urea nitrogen (BUN) or creatinine (waste products that should be filtered out by your kidneys), elevated levels of certain liver enzymes or bilirubin (a substance formed when red blood cells break down), low platelet counts (which can affect your blood’s ability to clot), or changes in consciousness not tied to specific neurological signs.
Severe low calcium levels (hypocalcemia), which is a dangerous condition, is commonly seen in TSS, and replacing the calcium in the body (repletion) is an essential part of the treatment. Low numbers of red blood cells (anemia), low platelet counts (thrombocytopenia), and longer than normal clotting times are also frequently seen in TSS patients. Doctors usually collect samples to gather and culture bacteria, which helps them identify and better treat the specific cause of the condition. For patients with fever and changes in mental status, a lumbar puncture (a procedure where a needle is used to collect fluid from the spinal canal) may be done to check for infections of the brain and spinal cord, like meningitis, after confirming that their blood clots normally.
Treatment Options for Toxic Shock Syndrome
If you’re suspected of having toxic shock syndrome, doctors will usually begin treatment by providing intravenous (IV) fluids to keep you hydrated. They’ll also examine you for any skin infections, focusing on potential areas where the bacteria of toxic shock syndrome could be living, such as tampons or nasal packing. It’s critical to remove these potential sources immediately and consult with a surgeon if there’s a need to clean out any wound or other source of infection.
Once they’ve ensured you are hydrated and free of potential sources of infection, doctors will generally give you antibiotics to fight off the bacteria. At first, they don’t know exactly which bacteria is causing the illness, so they use powerful broad-spectrum antibiotics that can kill many types of bacteria. These antibiotics often include vancomycin or linezolid, given the common presence of a bacteria called methicillin-resistant Staphylococcus aureus (MRSA), which is resistant to many antibiotics. Another antibiotic called clindamycin is also given because it has been proven to help suppress the toxins produced by the bacteria.
If the bacteria causing the illness is identified through blood or culture tests, then the antibiotics may be changed to ones that specifically target that bacterium. The duration of the antibiotic treatment usually ranges from a week to two weeks.
In case your condition is severe or you’re in shock, which means that your blood pressure is too low, doctors may use medicines called vasopressors to raise your blood pressure. They might also use a medicine called Intravenous immunoglobulin, or IVIG, which is thought to help neutralize the toxins produced by the bacteria. Importantly, all patients diagnosed with toxic shock syndrome will usually be cared for in an intensive care unit to closely monitor and manage their condition.
Please note that while steroids were once thought to help reduce the severity of the disease, current recommendations do not suggest their use, as they haven’t been shown to improve survival rates.
What else can Toxic Shock Syndrome be?
When trying to understand a certain medical situation, doctors often have to consider various conditions that might cause similar symptoms. Here are some of them:
- Scarlet fever
- Kawasaki disease
- Meningococcemia
- Toxic epidermal necrolysis
- Hemorrhagic shock
- Necrotizing Fasciitis or Gas gangrene
- Drug eruption
- Erythema multiforme
It’s crucial for healthcare professionals to examine all of these possibilities to make an accurate diagnosis.
What to expect with Toxic Shock Syndrome
The death rate for a severe infection called Streptococcal Toxic Shock Syndrome (TSS) can be more than 50%, especially if the diagnosis is late. However, for TSS caused by other bacteria (non-streptococcal), the death rate is less than 3%.
A small study conducted in France found that non-menstrual Toxic Shock Syndrome (TSS that happens outside of menstruation) had a higher death rate at 22%, compared to TSS that occurs during menstruation, which had no reported deaths. It’s important to note, however, that this study only involved 55 patients.
Possible Complications When Diagnosed with Toxic Shock Syndrome
Toxic shock syndrome can cause many complications, some of which are part of the condition’s diagnosis. The most severe complications can include damage to vital organs such as the kidneys and liver, causing them to fail, and issues with blood clotting. Additionally, toxic shock syndrome may also lead to other problems like glomerulonephritis, a type of kidney inflammation, and rheumatic fever, a disease that can affect the heart, joints, brain, and skin.
Major Complications:
- Damage to vital organs like kidneys and liver
- Problems with blood clotting
- Glomerulonephritis (inflammation of the kidneys)
- Rheumatic fever (disease affecting heart, joints, brain, and skin)
Preventing Toxic Shock Syndrome
At the moment, doctors typically do not give preventative treatment for GAS (Group A Streptococcus, a type of bacteria that can cause infections) to people living in the same household, even though these individuals are at a higher risk of getting GAS. However, it is crucial to let these close contacts know about the symptoms of a GAS infection and emphasize they should get medical help straight away if they start to see signs of the infection.
People over 65 years of age have a higher chance of dying from a GAS infection, so giving these individuals or those at a higher risk for GAS preventative treatment could make sense.
At the very least, hospitals should follow basic safety guidelines to prevent spread of the infection to other patients and hospital staff. The Centers for Disease Control and Prevention (CDC) suggests that for the first 24 hours of effective antibiotic treatment, the patient should be isolated to prevent any contact and droplet spread of the infection.
