Toxic shock syndrome: Symptoms, causes, and diagnosis

Toxic shock syndrome is a potentially fatal condition that starts with a staphylococcal or streptococcal strain of bacteria.

Women aged 15 to 25 years who use tampons during menstruation appear to have a higher risk of developing toxic shock syndrome (TSS), but it can happen to anyone.

The condition was first noted as a health hazard for women of reproductive age in 1980, when several healthy women from different states died, following an unexplained illness that involved a fever, shock, and multiple organ failure.

Various cases had been noted since the 1920s, but in 1980, TSS became a notifiable disease.

TSS is rare. Small studies suggest that it affects around 3 women of reproductive age in every 100,000 every year in the United States.

In 1980, the annual incidence was around 6 in every 100,000 women aged 19 to 44 years, in the U.S. However, after 1986, following the introduction of federal regulations and the removal of super-absorbent tampons from the market, the numbers decreased, according to the National Organization for Rare Diseases (NORD), and they may be as low as 1 in every 100,000.

Signs and symptoms

[tampon use increases risk of TSS]
Tampon use can increase the risk of TSS.

The two types of TSS are:

Staphylococcal TSS, caused by the Staphylococcus aureus (S. aureus) bacteria

Streptococcal TSS (STSS), caused by group A Streptococcus, or “strep,” bacteria

Signs and symptoms of TSS develop suddenly and progress quickly. The first indication is normally a sudden, high fever.

The following normally appear within a few hours:



Sunburn-like skin rash, particularly on the palms and soles

Redness of eyes, mouth and throat


Feeling faint

Muscle aches



Hypotension, or low blood pressure



The condition can progress to kidney failure, shock, and death within 48 hours.

Anyone who has been using tampons or who has a skin wound or infection and experiences the signs and symptoms described above, or if you have a skin or wound infection, should call a doctor immediately. Any tampon should be removed immediately.

[group A strep infection TSS]
A group A strep infection can lead to TSS.

Tampon use is implicated in 55 percent of cases, but another 15 percent are linked to childbirth and infected wounds.

From December 2015 to March 2016, five cases of menstrual-related TSS were reported in Michigan State. Four of the women were using super-absorbency tampons.

The bacteria that cause TSS are not uncommon. Between 20 percent and 30 percent of all humans carry S. aureus on their skin and nose, usually without complications. Most people have antibodies to protect them. It may be that some people do not develop the necessary antibodies.

One possibility is that the super-absorbent tampons, the ones that stay inside the body the longest, become breeding grounds for bacteria.

Another is that the tampon fibers scratch the vagina, making it possible for bacteria to get through and into the bloodstream.

Either the action or the composition of the tampons, combined with pre-existing staphylococcal bacteria in the vagina, probably trigger the disease.

However, both there is no compelling evidence to support either of these.

Streptococcal TSS can develop after minor trauma, or surgery, or as a result of a viral infection or the use of non-steroidal anti-inflammatory drugs (NSAIDS).

The bacteria enter the body through wounds, localized infections, the vagina, the throat, or burns. The bacteria produce toxins that enter the bloodstream and spread to all the organs. They interfere with the process of the blood pressure regulation, leading to hypotension, or low blood pressure.

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