Clinical Information on Toxic Shock Syndrome

Basic information for Toxic Shock Syndrome


  • Toxic shock syndrome (TSS) is a condition which may be caused by either Staphylococcus aureus 1 or Streptococcus pyogenes (group A streptococci) 2  – the latter is described in the article on GAS infections
  • TSS is characterized by rapid onset of high fever, vomiting, watery diarrhea, sore throat, myalgia and headache in a previously healthy person
  • The disease was first described in 1978 and was known in wider circles in 1980 during a number of disease cases in younger women assicieret with tampon use by menstruation;hence the name tamponsyge


  • Incidence and prevalence
    • The condition is rare
    • The incidence has decreased considerably since the first cases – primarily because of the information and changes in the way tampons are manufactured in
  • Age
    • Initially so that up to 90% of cases in women of childbearing age and most often among young women
    • Clinical disease occurred during the menstrual period and were associated with the use of highly absorbent tampons

TSS related to menstruation

  • Originally, so that an incidence of between 6 and 12 per. 100,000 persons, but with changes in the method of production fell to about this 1 case per. 100000
  • It seems in recent years to be a slight increase in incidence – mainly because cases are not associated with tampon use, is slightly increasing
  • Recent estimates indicate an incidence of approximately 3 per. 100,000 people

Etiology and pathogenesis


  • The syndrome can occur in all patients with a focus of toxin yellow staphylococci
  • Previously, the condition most common in menstruating women who had had tampon lying too long
  • However, staphylococci from the nasopharynx, vagina, rectum and wounds all been associated with the condition
  • TSS are often caused by toxic shock syndrome toxin (TSST-1)
  • Situations not related to menstruation, is often caused by strains that do not produce TSST-1
    • Staphylococcal enterotoxin B, or C 1 may also mediate mode


  • Staphylococcus aureus is an aerobic, Gram-positive bacterium
  • Causes different infections from folliculitis and hudabcesser to bacteremia and endocarditis
  • The bacterium colonizes the skin and mucous membranes in 30-50% of healthy adults and children, mostly in the front part of the nose, skin, vagina and rectum
  • S. aureus can multiply in the tissues and produce a number of enzymes which induce inflammation and abscesses
  • Many strains produce exotoxins that leads to three other syndromes:
    • food poisoning – caused by intake of S. aureus enterotoxin
    • “Scalded skin syndrome” – caused by an exfoliative toxin
    • TSS – caused by toxic shock syndrome toxin-1 (TSST-1) and other enterotoxins
  • Exotoxins cause disease because they are super antigens; that is molecules that activate large amounts of T cells – up to 20% of all T cells at the same time, resulting in a massive cytokine production

Pathogenesis of TSS

  • The pathogenesis involves the establishment of a toxin producing bacterial strain in a non-immunized subject, under conditions which favor the growth of bacteria, for example. an aerobic environment rich in nutrients
  • The host’s antibody response to S. aureus exotoxins play an important role in the pathogenesis
  • 70-80% of all individuals develop antibodies to TSST-1 during the teenage years and by 40 years of age have 90-95% such antibodies
  • Patients with clinically TSS lack antibodies to TSST-1 and also appears to have reduced ability to generate such antibodies


  • A78 Infectious disease IKA


  • A483 Toxic shock syndrome


diagnostic criteria

  • Fever of 38.9 ° C
  • Diffuse macular rash erythematous, flaking of the palms and soles during the two weeks
  • hypotension
  • Involvement of three or more bodies
    • The gastrointestinal tract (vomiting, diarrhea)
    • Kidney or liver failure
    • Hyperaemia of the mucous membranes (non-purulent conjunctivitis)
    • thrombocytopenia
    • Myalgia with elevated CK
    • Confusion with normal spinal fluid
    • hypocalcemia


  • meningococcemia
  • Scarlet fever (Group A streptococci)
  • Toxic epidermal necrolysis
  • Kawasaki’s syndrome
  • Rocky Mountain spotted fever

Medical history

  • The symptomatology may vary due to the effect of S. aureus -toksinet, but there is no difference in principle in the menstrual and non-menstrual-related disease
  • The condition usually starts acutely in a previously healthy young woman who has used tampons
  • In many symptoms start within several days after the start of menstruation in a woman who has used tampon, or after surgery; exceptionally symptoms may occur later
  • There are high fever, vomiting and watery diarrhea
  • Sore throat, myalgia and headache are frequent

clinical findings

  • All patients with safe TSS fever> 38.9 ° C, hypotension and skin manifestations
  • Diffuse macular rash erythematous
  • Non-purulent conjunctivitis
  • hyperemic vaginal mucosa
  • In severe cases there hypotension with kidney and heart failure


  • Defined as systolic blood pressure less than 90 mmHg and orthostatic reduction in diastolic pressure of 15 mm Hg or orthostatic dizziness or syncope
  • Occurs rapidly and can lead to ischemia and organ failure as kidney and heart failure
  • Hypotension due to decreased systemic vascular resistance, as well as non-leakage of hydrostatic fluid from intravaskulærrummet to the interstitial space, both mechanisms is due to the massive release of cytokines induced by toxins

Skin manifestations

  • Various skin manifestations can be seen by TSS
  • The initial erythroderma involving both skin and mucous membranes and is characterized by a diffuse red, macular rash, which is reminiscent of suntanning, but which also includes the palms and soles
  • Slimhindeaffektionen include conjunctival hemorrhage and hyperemia of the lining of the vagina and mouth / throat
  • The patient will also have edema
  • Sensymptomer may be a maculopapular rash itching that may occur one to two weeks after initiation of the disease, and peeling of the soles of the feet, and palms of the hands typically occurs 1-3 weeks after disease onset
  • Some patients experience loss of hair and nails 1-2 months later

Multi-organ involvement

  • TSS can affect all body systems
  • Many patients complain of diffuse myalgias and muscle weakness
  • Gastrointestinal symptoms are frequent, particularly acute diarrhea
  • Both prerenal, renal and renal failure may occur and results in metabolic disorders
  • Encephalopathy can manifest as disorientation, confusion and convulsions, and is probably due to cerebral edema
  • Persistent neuropsychological genes can develop – such as headache, loss of memory and poor concentration

additional studies

  • Detection of S. aureus is not necessary to make the diagnosis
  • Yellow staphylococci can be cultured from vaginal discharge or ulcers
  • Blood culture is usually negative (95%)

When to refer the patient?

  • On suspicion of TSS


Treatment goals

  • Survival

Generally about the treatment

  • Correcting shock
  • Correcting kidney and lung failure and disseminated intravascular coagulation
  • antibiotics intravenously
  • Drainage of focal accumulations of yellow staphylococci

Medical treatment

infection Treatment

  • antibiotics intravenously
    • Probably antibiotics such as clindamycin , which suppresses protein synthesis more efficient than cell wall-active substances such as beta-lactam antibiotics
    • On the empirical basis is often recommended a combination of clindamycin  and dicloxacillin
    • Duration of treatment is 1-2 weeks
  • immunoglobulin
    • This will probably be used in most places
  • corticosteroids
    • There is no evidence for the use of steroid

shock Treatment

  • fluid therapy
    • Significant fluid replacement may be required for several days
  • pressor
    • May be necessary

other treatment

  • Search foreign


  • Drainage of any foci
  • At postoperative patients seeing surgical wounds often do not appear to be infected due to decreased inflammatory response, but the wound should still Exploration, if the patient meets the criteria for TSS

preventive treatment

  • When using tampons
    • Must be changed regularly; tampons should be no more than 12 hours
    • Check that all the tampons are removed

Course, complications and prognosis


  • Initially, up to 30% of menstruating women with TSS relapses
    • Recidiverne is usually milder


  • Kidney and heart failure
  • shock
  • ARDS (adult respiratory distress syndrome)
  • Disseminated intravascular coagulation (DIC)


  • Mortality appears to be greater for non-tamponassocieret TSS; A recent French study, mortality was 0 in women with tamponassocieret TSS 3

patient Information

What you should inform the patient

  • The need to change tampons regular
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