the toxic shock syndrome - Symptoms, signs and Treatment.

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What is the toxic shock syndrome

This condition was first described in 1978. The majority of cases happen in women during their periods and there is a link with the use of tampons particularly if they are accidentally retained for too long. The illness is characterised by fever and shock (drop in blood pressure). The early cases were associated with almost 10% mortality but with modern therapy this rate has fallen to less than 3%.

Toxic shock syndrome (TSS) is a rare but potentially fatal disease caused by a bacterial toxin. The causative-positive bacteria include Staphylococcus aureus and Streptococcus pyogenes.

Routes of infection

This infection can occur via the skin (e.g., cuts, surgery, burns), vagina (via tampon, prolonged condom exposure), or pharynx.  Toxic shock syndrome has also been associated with the contraceptive sponge and diaphragm birth control methods. Most of the large number of individuals who are exposed to or colonized with toxin-producing strains of S. aureus or S. pyogenes do not develop toxic shock syndrome probably because many people have protective antibodies against the causative toxins.

The number of reported staphylococcal toxic shock syndrome cases has decreased significantly in recent years. Approximately half the cases of staphylococcal TSS reported today are associated with tampon use during menstruation, usually in young women, though TSS also occurs in children, men, and non-menstruating women. In the US in 1997, only five confirmed menstrual-related TSS cases were reported, compared with 814 cases in 1980. It has been estimated that about 10 out of every 100,000 menstruating females will get TSS.

The toxin implicated in menstrual TSS is capable of entering the bloodstream by crossing the vaginal wall in the absence of ulcerations. Women may avoid problems by choosing a tampon with the minimum absorbency needed to control menstrual flow and using tampons only during active menstruation.

History - The Initial description of toxic shock syndrome

The term toxic shock syndrome was first used in 1978 by a Denver pediatrician, Dr. J.K. Todd, to describe the staphylococcal illness in three boys and four girls aged 8-17 years. The authors of the study noted that reports of similar staphylococcal illnesses had appeared occasionally as far back as 1927. Most notably, the authors at the time failed to consider the possibility of a connection between toxic shock syndrome and tampon use, as three of the girls who were menstruating when the illness developed were using tampons.

Symptoms and diagnosis

Symptoms of toxic shock syndrome vary depending on the underlying cause. In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections. TSS resultant of infection with the bacteria Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress to stupor, coma, and multi-organ failure. The characteristic rash resembles a sunburn, and can involve any region of the body, including the lips, mouth, eyes, palms and soles.

 

The Diagnosis of TSS is strictly based on CDC criteria:

1. Body temperature > 38.9 °C (102.02 °F)
2. Systolic blood pressure < 90 mmHg
3. Diffuse rash especially of the palms and soles
4. Involvement of three or more organ systems:
   • Gastro-intestinal (vomiting and / or diarrhea)
   • Mucous membrane hyperemia (vaginal, oral, conjunctival)
   • Hepatic inflammation (AST, ALT > 2x normal)
   • Renal failure (serum creatinine > 2x normal)
   • Thrombocytopenia (platelet count < 100,000 / mm³)
   • Cerebral involvement (confusion without any focal neurological findings)

Prevention

You can reduce the risk of toxic shock syndrome by either avoiding tampons or alternating them with sanitary napkins. Use only tampons with the lowest absorbency that will handle menstrual flow and change the tampons frequently. Between menstrual periods, store tampons away from heat and moisture where bacteria can grow — for example, in a bedroom rather than in a bathroom closet.

Treatment

Women wearing a tampon at the onset of symptoms should remove it immediately. The severity of this disease warrants hospitalization. Treatment consists of aggressive fluid administration and antibiotics, such as cephalosporins, penicillinase-resistant semisynthetic penicillins or vancomycin.

With proper treatment, patients usually recover in two to three weeks. The condition, however, can be fatal within hours. Sometimes patients are admitted to the intensive care unit for supportive care in case of multiple organ failure.

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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.