Toxic Shock Syndrome

Topic Overview

What is toxic shock syndrome?

Toxic shock syndrome (TSS) is a rare, often life-threatening illness that develops suddenly after an infection and can rapidly affect several different organ systems, including the lungs , kidneys , and liver . Since toxic shock syndrome progresses quickly, immediate medical treatment is needed.

What causes toxic shock syndrome?

Toxic shock syndrome is the rare result of infection by Streptococcus pyogenes (group A strep) or Staphylococcus aureus (staph) bacteria. These bacteria make toxins that cause TSS. These bacteria are common but usually don't cause problems. They can cause infections of the throat or skin that are easy to treat, such as strep throat or impetigo. In rare cases, the toxins enter the bloodstream and cause a severe immune reaction in people whose bodies can't fight these toxins. The body's reaction causes the symptoms associated with TSS.¹

• Strep TSS most often occurs after childbirth, the flu (influenza), chickenpox, surgery, minor skin cuts or wounds, or injuries that cause bruising but may not break the skin.
• Staph TSS most often occurs after prolonged use of a tampon (menstrual TSS) or after a surgical procedure, such as nose surgery using packing bandages (nonmenstrual TSS).

What are the symptoms?

TSS symptoms develop quickly and can become life-threatening within 2 days. First signs of TSS usually include:

• Severe flu-like symptoms, such as muscle aches and pains, stomach cramps, a headache, or a sore throat.
• Sudden fever over 102 °F (38.9 °C).
• Vomiting and diarrhea.
• Signs of shock, including low blood pressure and rapid heartbeat, often with lightheadedness, fainting, nausea, vomiting, or restlessness and confusion.
• A rash that looks like a sunburn. The rash can be over several areas of your body or just in specific places such as the armpits or the groin.
• Severe pain at the site of an infection (if a wound or injury to the skin is involved).
• Redness in the nasal passages and inside the mouth.

Other TSS symptoms that may follow include:

• Conjunctivitis (pinkeye).
• Involvement of more than one organ system, most commonly the lungs and kidneys.
• Blood infection (sepsis) that affects the entire body.
• Skin tissue death (necrosis), which occurs early in the syndrome.
• Skin tissue shedding, which occurs during recovery.

Toxic shock symptoms vary slightly depending on the strep or staph bacteria involved.

How is toxic shock syndrome diagnosed?

Because it progresses so quickly, toxic shock syndrome is usually diagnosed and treated based on symptoms and signs of infection without waiting for laboratory results. Additional blood and tissue tests can help identify the type of bacterium causing the infection.

How is it treated?

Emergency treatment often requires intravenous fluid replacement and hospital intensive care, particularly when the body has gone into shock. Further treatment involves antibiotics to kill the bacteria involved, removing any source of infection, and treating any complications. If there are no major complications, most people recover completely in 1 to 2 weeks with antibiotic treatment.

If you think you have toxic shock syndrome, call your doctor immediately. If you have symptoms of shock, such as severe weakness, dizziness, or lightheadedness, immediately seek emergency medical care. Since TSS can cause life-threatening complications, you will most likely need treatment in a hospital where your condition can be closely monitored.

Frequently Asked Questions

Cause

The strep or staph bacteria that produce the toxins that cause toxic shock syndrome (TSS) are common, but they are usually not harmful. Most of the time, these bacteria cause only mild infections of the throat, such as strep throat, or of the skin, such as impetigo. In rare cases, however, the toxins produced by the bacteria enter the bloodstream and cause a severe, rapidly progressing immune reaction.

The immune reaction that leads to toxic shock syndrome is typically linked to a lack of specific antibodies against a strep or staph toxin. Younger people are less likely than adults to have developed these antibodies.

Outbreaks of TSS can occur in hospitals and long-term care facilities where people live in close surroundings.

Symptoms

The rapid development of symptoms is one of the most important clues that you may need immediate medical care for toxic shock syndrome (TSS).

Toxic shock symptoms range in severity, depending on the strep or staph bacteria involved.

General symptoms of toxic shock syndrome include:

• Flu-like symptoms, such as muscle aches and pains, stomach cramps, a headache, or a sore throat. The flu-like symptoms of TSS are common to many illnesses, but they develop much more quickly and are more severe than symptoms caused by a less serious illness.
• Sudden fever over 102 °F (38.9 °C).
• Vomiting and diarrhea.
• A rash that looks like a sunburn.
• Signs of shock, including low blood pressure and rapid heartbeat, often with lightheadedness, fainting, nausea, vomiting, or restlessness and confusion.
• Conjunctivitis (pinkeye).
• Pain at the site of an infection (if a wound or injury to the skin is involved).
• Involvement of more than one organ system, most commonly the lungs and kidneys.
• Blood infection (sepsis) that affects the entire body.
• Skin tissue death (necrosis), which occurs early in the syndrome.
• Skin tissue shedding, which occurs during recovery.

Strep nonmenstrual TSS. Symptoms typically develop:

• In women who have recently given birth, from 2 or 3 days up to several weeks after delivery.
• In people who have infected surgical wounds, from 2 days to 1 week after surgery.
• In people with respiratory infections, from 2 to 6 weeks after respiratory symptoms begin.

Staph menstrual TSS. Symptoms typically develop 3 to 5 days after a woman starts her period, if she is using tampons.

Staph nonmenstrual TSS. Symptoms typically develop as soon as 12 hours after a surgical procedure, particularly those in which surgical packing is used, such as a rhinoplasty.

What Happens

Toxic shock syndrome (TSS) symptoms can rapidly affect several different organ systems, including the lungs , kidneys , and liver . A rash that looks like a sunburn may also occur early in the illness. The rash is often followed 7 to 14 days later by scaling, peeling skin, especially on the palms of the hands and soles of the feet.

Children are less likely than adults to develop the more serious complications of toxic shock syndrome.

Dangerous complications of toxic shock syndrome include:

• Shock, causing decreased blood and oxygen circulation to the vital organs.
• Acute respiratory distress syndrome (ARDS). Lung function decreases, breathing becomes difficult, and blood oxygen levels drop.
• Disseminated intravascular coagulation (DIC). This condition causes the clotting factors in the blood to become too active. Many blood clots may form throughout the body, which uses up the clotting factors. This can cause excessive bleeding.
• Kidney failure, also called end-stage renal disease. Failure happens when kidney damage is so severe that treatment with dialysis or a kidney transplant is needed to prevent death.

Talk with your doctor about possible ongoing complications if you have more episodes of menstrual toxic shock syndrome.

What Increases Your Risk

Some people may be naturally more susceptible to toxic shock syndrome (TSS) than others, even in the absence of risk factors. These people lack specific antibodies against the toxins of strep or staph. People with immune system problems, such as diabetes, cancer, or autoimmune diseases, are also at higher risk for toxic shock syndrome because they are also more likely to lack the specific immune system response needed to fight the toxins.

Risk factors for menstrual TSS

The prolonged use of a tampon, especially the superabsorbent type, increases a woman's risk for menstrual TSS. If you have had menstrual TSS in the past, you have an increased risk of developing it again.

Risk factors for strep nonmenstrual TSS

Chickenpox is the most important risk factor for a strep bacterial infection leading to TSS in children.² Scratching chickenpox blisters can lead to group A streptococcal skin infections, increasing a child's risk of developing TSS.

In adults, risk factors include:

• Recent childbirth. A woman who is pregnant or has recently given birth has a greater risk of developing strep TSS, especially if one of her children has strep throat. Any pregnant woman or new mother with a child who shows signs of strep throat should talk to her gynecologist or obstetrician.
• Recent surgical abortion.
• Skin injury, including cuts, burns, deep bruises, insect and animal bites, sores caused by chickenpox or shingles, mastitis, boils, piercings, and tattoos.
• Influenza.
• Infections in the muscles, such as myositis, or in joints, such as bursitis.
• Recent respiratory infections, such as sinusitis, sore throat (pharyngitis), laryngitis, tonsillitis, or pneumonia.

Risk factors for staph nonmenstrual TSS

The risk for staph nonmenstrual TSS is increased by:

• Use of contraceptive sponges, diaphragms, or an intrauterine device (IUD).
• Skin injury, including surgical wounds, especially surgery on the nose when packing bandages are used.
• Abscesses.
• Recent respiratory infections, such as sinusitis, sore throat (pharyngitis), laryngitis, tonsillitis, or pneumonia.
• History of staph menstrual TSS.

Risk of recurrence

After having menstrual TSS, about 30% of women have at least one repeat episode.³ If you have just had menstrual TSS, you are most likely to have another case during your next three menstrual periods, especially if the original infecting bacteria was not eliminated by antibiotic treatment. Killing the infecting bacteria is especially important because research shows that about 66% of women do not develop antibodies after having menstrual TSS.⁴ Without antibodies, you are still vulnerable to the bacterial toxins that trigger toxic shock syndrome.

If you have had TSS related to tampon use, you can reduce your chances of getting it again by taking a few simple precautions. For more information, see the Prevention section of this topic.

People who have had nonmenstrual TSS are at increased risk of getting it again, although recurrence is rare.⁴

When To Call a Doctor

If you have toxic shock syndrome, you need immediate medical treatment and need to be hospitalized. Call your doctor immediately if you become suddenly ill with a fever, a rash that looks like a sunburn, or signs of shock, especially if you have:

• Been using tampons, a diaphragm, or a contraceptive sponge.
• Recently given birth.
• Had recent surgery on the nose and have nasal packing bandages.
• Increasing pain at the site of recent surgery or at the site of a bruising injury.
• Had a recent respiratory infection.
• Had a recent skin injury that may have signs of infection.
• Had toxic shock syndrome before.

Watchful Waiting

If you have toxic shock syndrome, you need immediate medical treatment and probably need to be hospitalized. It is not appropriate to wait and observe your symptoms without medical treatment. Waiting may make the infection worse.

Who To See

Usually by the time a person who has toxic shock syndrome (TSS) sees a health professional, the illness has progressed rapidly and the person is very sick. Health professionals who can diagnose and treat toxic shock syndrome include:

• Critical care medicine specialists.
• Emergency medicine specialists.
• Family medicine doctors.
• Gynecologists.
• Infectious disease specialists.
• Internists.
• Pediatricians.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Usually by the time a person who has toxic shock syndrome (TSS) sees a health professional, the illness has progressed rapidly and is severe. Treatment for shock is usually needed before any test results are available.

If a health professional suspects that you have toxic shock syndrome, you will have several types of tests, including:

• Routine complete blood count (CBC) of red and white blood cells, platelets, and other basic qualities of your blood.
• Cultures of blood and other body fluids and tissues for signs of strep or staph bacteria. For menstrual TSS, a vaginal fluid sample is tested. For nonmenstrual TSS, a swab or sample of a suspected wound, lesion, or other affected area is tested. Blood cultures do not usually detect staph TSS when it is present, but strep can be identified in a sample of blood or cerebrospinal fluid (CSF) or by a tissue biopsy. Cultures from the throat, the vagina, or a sputum sample may also show the bacteria.
• Chest X-ray, to look for signs of damage to the lungs (respiratory distress syndrome).
• Tests to rule out other infections that can cause symptoms similar to those of TSS, such as an infection of the blood (sepsis), a tick-borne bacterial infection (Rocky Mountain spotted fever), a bacterial infection caused by contact with the urine of infected animals (leptospirosis), or typhoid fever.

Other tests are sometimes necessary, depending on how the illness has developed and what problems it has caused.

Treatment Overview

By the time a person with toxic shock syndrome (TSS) sees a health professional, immediate medical treatment is usually necessary. Because TSS can progress rapidly and cause life-threatening complications, treatment almost always takes place in a hospital where a person's condition can be closely monitored. Treatment for shock or organ failure is usually necessary before any test results are available. Admission to the intensive care unit (ICU) is usually needed when a person shows signs of shock or has problems breathing (respiratory failure).

Treatment for strep or staph toxic shock syndrome includes:

• Removal of the source of the infection. If a woman is using a tampon, diaphragm, or contraceptive sponge, it is removed immediately. Infected wounds are usually drained and cleaned to rid the area of bacteria. Your doctor may give you a shot to numb the area in order to use a scalpel or scissors to remove dead or severely infected tissue. This is called surgical debridement. As soon as the source of the infection is removed, a person's condition often improves rapidly.
• Treatment of complications of the illness, including low blood pressure, shock, and organ failure. The specific treatment depends on what problems have developed. Large amounts of intravenous (IV) fluids are typically used to replace fluids lost from vomiting, diarrhea, and fever and to avoid complications of low blood pressure and shock.
• Antibiotics to kill the bacteria that are producing the toxins causing TSS. Clindamycin stops toxin production and is started immediately to treat symptoms.¹ Other medicines, such as cloxacillin or cefazolin, may be added when the specific strep or staph bacteria is identified by lab tests. Strains of Staphylococcus aureus that are resistant to medicines such as cloxacillin or cefazolin have spread throughout the United States. These staph strains are called methicillin-resistant Staphylococcus aureus (MRSA). Other antibiotics may be needed to kill these bacteria. These antibiotics include vancomycin, daptomycin, linezolid, or tigecycline.

When there are no major complications, most people recover completely in 1 to 2 weeks with antibiotic treatment.

Strep TSS has about a 50% death rate.⁵ This may be because strep TSS can be more difficult to identify early before serious complications develop, such as blood infection (sepsis) or a rare bacterial infection that can destroy skin (necrotizing fasciitis).

Staph TSS is serious but leads to death in only about 5% of people when identified and treated properly.⁵

Prevention

You can significantly lower your risk of toxic shock syndrome (TSS) by taking a few simple precautions.

• Avoid using tampons and barrier contraceptives (such as a diaphragm, cervical caps, or sponges) during the first 12 weeks after childbirth, when the risk for TSS is higher.
• If you have had menstrual TSS, do not use tampons, barrier contraceptives, or an intrauterine device (IUD).

Careful tampon, diaphragm, and contraceptive sponge use

• Follow the directions on package inserts when using tampons, diaphragms, or contraceptive sponges.
• Wash your hands with soap before inserting or removing a tampon, diaphragm, or contraceptive sponge.
• Change your tampon at least every 8 hours, or use tampons for only part of the day. Do not leave your diaphragm or contraceptive sponge in for more than 12 to 18 hours.
• Alternate wearing tampons and sanitary pads. For example, use pads at night and tampons during the day.
• Use tampons with the lowest absorbency that you need. The risk of TSS is higher with superabsorbent tampons.

Caring for skin wounds to prevent skin infection

• Keep all skin wounds clean to prevent infection and promote healing. This includes cuts, punctures, scrapes, burns, sores from shingles, insect or animal bites, and surgical wounds.
• Keep children from scratching chickenpox sores.

If signs of infection appear, seek medical evaluation immediately. These signs include:

• Increased pain, swelling, redness, or warmth around the affected area.
• Red streaks extending from the affected area.
• Drainage of pus from the area.
• Swollen lymph nodes in the neck, armpit, or groin.
• Fever.

Preventing strep infection during pregnancy or after giving birth

A woman who is pregnant or has recently given birth has a greater risk of developing strep TSS, especially if one of her children has strep throat. Any pregnant woman or new mother with a child who shows signs of strep throat should talk to her gynecologist or obstetrician.

Home Treatment

Toxic shock syndrome (TSS) is a quickly progressing, life-threatening condition that cannot be treated at home. If you think you may have TSS, seek immediate medical attention.

You can take measures to prevent TSS.

• Avoid using tampons and barrier contraceptives during the first 12 weeks after childbirth, when the risk for TSS is higher.
• Follow the directions on package inserts when using tampons, diaphragms, or contraceptive sponges. Change your tampon at least every 8 hours, or use tampons for only part of the day. Do not leave your diaphragm or contraceptive sponge in for more than 12 to 18 hours.
• Keep all skin wounds clean to prevent infection and promote healing. This includes cuts, punctures, scrapes, burns, sores from shingles, insect or animal bites, and surgical wounds.
• Keep children from scratching chickenpox sores.
• If you have had menstrual TSS, do not use tampons, barrier contraceptives (such as a diaphragm, cervical caps, or sponges), or an intrauterine device (IUD).

Medications

Antibiotics are used to treat toxic shock syndrome. The sooner antibiotics are started, the less likely the possibility of serious complications. Antibiotics are given as long as necessary, which depends on the strep or staph bacteria identified and the severity of symptoms.

Antibiotics may also help prevent a repeat episode of toxic shock syndrome.

Intravenous immunoglobulin (IVIG) can be used when toxic shock syndrome is severe or does not improve with antibiotics. Intravenous immunoglobulin works differently than antibiotics. It contains antibodies that can help the body remove the specific toxins causing TSS. But experts have not determined if IVIG is effective for treating TSS.

Your doctor may give you medicines to help with your blood pressure and to help your organs work better.

With prompt treatment and no major complications, most people recover completely in 1 to 2 weeks.

Surgery

Surgery is rarely needed to treat toxic shock syndrome (TSS) caused by staph bacteria, but it is an important part of treatment for TSS caused by strep. In selected cases, surgically removing infected tissue leads to a significant improvement in a person's condition. For example, surgery may be necessary when:

• TSS has developed after a surgical procedure, and the surgical wound needs to be drained and cleaned to remove the source of the infection.
• Strep bacteria are causing necrotizing fasciitis, a bacterial infection that destroys skin, and the dead tissue and toxins produced by the bacteria must be removed.

Strep TSS with necrotizing fasciitis progresses rapidly and is life-threatening, so emergency surgery may be needed to remove the source of infection. For more information, see the topic Necrotizing Fasciitis (Flesh-Eating Bacteria).

Other Treatment

In the hospital, you may need intravenous (IV) fluids and protein (albumin) to replace that lost by your body.

There are no other treatments for toxic shock syndrome available at this time.

Other Places To Get Help

Organization

Related Information

• Chickenpox (Varicella)
• Necrotizing Fasciitis (Flesh-Eating Bacteria)

References

Citations

1. American Academy of Pediatrics (2006). Toxic shock syndrome. In LK Pickering et al., eds., Red Book: 2006 Report of the Committee on Infectious Diseases, 27th ed., pp. 660-665. Elk Grove Village, IL: American Academy of Pediatrics.

2. Laupland KB, et al. (2000). Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Pediatrics, 105(5): E60.

3. Ainbinder SW, et al. (2007). Toxic shock syndrome section of Sexually transmitted diseases and pelvic infections. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics and Gynecology, 10th ed., pp. 689-691. New York: McGraw-Hill.

4. Andrews MM, et al. (2001). Recurrent nonmenstrual toxic shock syndrome: Clinical manifestations, diagnosis, and treatment. Clinical Infectious Diseases, 32(10): 1470-1479.

5. Moreillon P, et al. (2005). Staphylococcus aureus (including staphylococcal toxic shock). In GL Mandell et al., eds., Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 6th ed., vol. 2, pp. 2321-2351. Philadelphia: Elsevier.

Other Works Consulted

• Deresiewicz RL (2007). Toxic shock syndrome. In RE Rakel, ET Bope, eds., Conn's Current Therapy 2007, pp. 99-101. Philadelphia: Saunders Elsevier.

• Fu Y (2000). Toxic shock syndrome. In RE Rakel, ed., Saunders Manual of Medical Practice, 2nd ed., pp. 1118-1120. Philadelphia: W.B. Saunders.

• National Center for Infectious Diseases, Centers for Disease Control and Prevention (2005). Group A Streptococcal (GAS) Disease. Available online: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm.

• Stevens DL (2008). Streptococcal infections. In L Goldman, D Ausiello, eds., Cecil Medicine, 23rd ed., vol. 2, pp. 2176-2183. Philadelphia: Saunders Elsevier.

• Stevens DL, et al. (2006). Successful treatment of staphylococcal toxic shock syndrome with linezolid: A case report and in vitro evaluation of the production of toxic shock syndrome toxin type 1 in the presence of antibiotics. Clinical Infectious Diseases, 42: 729-731.

• Waldvogel F (2004). Toxic shock syndrome. In DL Heymann, ed., Control of Communicable Diseases Manual, 18th ed., pp. 506-507. Washington, DC: American Public Health Association.

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