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Toxic shock syndrome

Introduction

Toxic shock syndrome (TSS) is a rare, life-threatening bacterial infection.

The bacteria responsible, staphylococcus aureus, invade the body's bloodstream and then release poisonous toxins. These toxins then cause a massive drop in blood pressure resulting in symptoms of shock. They also begin to damage tissue, including skin and organs and can disturb many vital organ functions. Left untreated, the combination of shock and organ damage can result in death. 

Around 20 people develop TSS in the UK every year, of which two or three will die because of the condition.

The condition is more common amongst young people, particularly in women under the age of 25. It is thought that this is because many older people have developed immunity to the toxins produced by the bacteria. However, cases have been recorded in people of all ages, including children.

For reasons that are still not understood, a significant proportion of cases occur in women who are menstruating and using a tampon. Particularly tampons designed to be 'super absorbent'.

TSS can also occur as a result of an injury, burn or as a complication of a localized infection such as a boil.

If detected early enough, treatment for TSS is normally successful. Treatment includes using antibiotics while providing support to the other functions of the body that have been affected by TSS.

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Symptoms

The symptoms of Toxic Shock Syndrome (TSS) normally begin with a sudden high fever. Other symptoms will then rapidly develop, normally in the course of a few hours. They include:

  • vomiting,
  • diarrhoea,
  • a skin rash much like sunburn,
  • muscle aches,
  • fainting or feeling faint,
  • confusion, and
  • dizziness.

When to seek medical advice

If you develop a sudden fever and one or more of the other symptoms listed above, it is still extremely unlikely that you have TSS. Nevertheless, symptoms like these should never be ignored and you should contact your GP immediately. If your GP is unavailable contact your local out-of-hours service or NHS Direct on 0845 4647.

If you are wearing a tampon you should remove it immediately. You should also tell your GP or doctor if you have been using a tampon, or if you have recently suffered a burn or skin injury. Or if you have a localised infection, such as a boil or a blister that has become infected.

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Causes

Despite being studied for over twenty years there is much about toxic shock syndrome (TSS) that is not understood.

The bacteria involved in TSS, staphylococcus aureus, can be found on the skin and in the nose of approximately 20 to 30% of all people and usually causes no serious problems.

It seems that most people have special toxin-fighting proteins known as antibodies, which can protect the body against these toxins. Though, for reasons that are unknown, a small percentage of people do not develop these specific antibodies.

Also the role of tampons remains unexplained. One theory is that if a tampon is left in your vagina for some time, as is often the case with the more absorbent types of tampons, it can become a breeding ground for the bacteria. Another theory is that the fibres of the tampon may scratch your vagina, allowing the bacteria or the toxins to enter the blood. However, no evidence has been found to support either theory.

What is known is that the bacteria and their toxins can enter the body through a wound, burn, localised infection, the throat, or the vagina. The toxins are then spread through the skin until they enter the blood.

Once they reach the blood they interfere with the processes that regulate blood pressure causing it to drop, which results in the symptoms of shock such as dizziness and confusion. They also begin attacking tissues, including the skin and muscles as well as the organs.

Kidneys are particularly vulnerable as they are involved in filtering out waste products from your blood and kidney failure is a common complication in untreated TSS.

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Diagnosis

There is no single test for toxic shock syndrome (TSS). The condition is diagnosed by looking for the most common symptoms while checking for evidence of organ failure. Organ function can be tested in a variety of ways including blood and urine tests.

A confident diagnosis of TSS can usually be made when:

  • you have a temperature of above 38.9 °C (102.02 °F),
  • your systolic blood pressure is less than 90 mmHg (systolic is the pressure at which your blood pumps blood away from your heart and is measured in millimeters of mercury - 'mmHg'),
  • you have a skin rash, and
  • there is evidence that three or more of your organs have been affected by infection.

If all of the above are present then it is likely you have toxic shock syndrome

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Treatment

There are two important goals in the treatment of TSS. These are:

  • to fight the infection, and
  • to support any functions of the body that have been affected by infection.

Treatment will require admission to hospital, and some people will need to be treated in an intensive care unit.

Oxygen is given to support breathing and fluids will be administered in order to raise blood pressure and prevent dehydration.

If kidneys stop functioning, a dialysis machine is used. This is a device that can replicate the blood filtering processes of the kidneys.

If the toxins have damaged parts of the skin, or other extremities of the body such as the fingers or toes, the infected tissue will need to be drained and cleaned. In very severe cases, it may be necessary to surgically remove parts of the skin, or amputate (remove by surgery) an extremity of the body.

The infection can normally be treated by administering a combination of antibiotics directly into the bloodstream drip (intravenous).

In some cases immunoglobulin may also be used as well as antibiotics. Immunoglobulin are samples of donated human blood known to contain a high level of antibodies, which can be used to fight the toxins produced by the bacteria.

Most people will respond to treatment within a couple of days, but it may be several weeks before they are well enough to leave hospital.

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Prevention

The link between toxic shock syndrome (TSS) and tampon use is unclear. Research suggests that for cases which occur in women using tampons, tampon absorbency is a factor. For this reason it is important that you:

  • always use a tampon with the lowest absorbency suitable for period flow,
  • alternate tampons with a sanitary towel or panty liner from time to time during your period,
  • wash your hands before and after inserting a tampon,
  • change tampons regularly, as often as directed on the pack,
  • never insert more than one tampon at a time,
  • when using at night, insert a fresh tampon before going to bed and remove it on waking, and
  • make sure you remove the last tampon at the end of your period.

Information about TSS is contained in the tampons manufacturers instruction leaflet. This information is often updated, so it is important to read the leaflet regularly.

TSS has been known to recur in some people. If you have had TSS in the past, you should avoid using tampons.

If you are using a female barrier form of contraception such as a diaphragm, cap or contraceptive sponge, always follow the manufacturers' instructions about how long you can leave the device in your vagina. If these devices are left in for too long they can cause an infection, and possibly TSS.

If you have had TSS in the past, you may wish to use an alternative method of contraception.

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