Toxic shock syndrome

Toxic shock syndrome
Toxic shock syndrome

Toxic shock syndrome (TSS) is an uncommon but potentially serious illness that occurs when poisonous substances (toxins) produced by certain bacteria enter the bloodstream.

The toxins cause a type of blood poisoning caused by staphylococcal, or less commonly streptococcal, infections in the lungs, throat, skin or bone, or from injuries. Women using super-absorbent tampons during menstruation were found to be most likely to get toxic shock syndrome.

TSS first came to the attention of the public in the 1970s. Shortly after the introduction of a super-absorbent tampon, young women across the United States experienced an epidemic of serious but unexplained symptoms.

Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. The only thing they had in common was that they all were menstruating at the time they felt sick, and all were using tampons—especially super-absorbent products.

At its height, the epidemic affected 15,000 people in the United States each year between 1980 and 1984; 15% of the women died. Since the offending products were taken off the market, the numbers of TSS cases have declined sharply. As of 1998, only about 5,000 cases are diagnosed annually in the United States, 5% of which are fatal.

The decline is most likely due to the tampon manufacturers’ discontinuing the use of some synthetic materials, and the removal from the market of the brand of tampon associated with most cases of TSS. As of the early 2000s, most of these products are made with rayon and cotton.

In spite of TSS’s association with menstruating women, the disease can affect anyone of either sex or any age or race. The infection may occur in children, men, and non-menstruating women who are weakened from surgery, injury, or disease, and who cannot fight off a staphylococcal infection.

New mothers are also at higher risk for TSS, particularly if they had a caesarean section or if they are breastfeeding their infants.

Most cases reported in Western countries still involve menstruating women under age 30. TSS still occurs in about 17 out of every 100,000 menstruating girls and women each year; more than half of these cases are related to tampons. Between 5% and 10% of patients with TSS die.

In the developing countries, however, toxic shock syndrome often affects children. A recent report of staphylococcal TSS from Saudi Arabia concerned a four-month-old infant. Burns appear to increase the risk of TSS in children in all countries.

Streptococcal toxic shock syndrome (STSS)

Toxic shock syndrome infographic
Toxic shock syndrome infographic

A new type of toxic shock syndrome is caused by a different bacterium, called Group A streptococcus. This form of TSS is called streptococcal toxic shock syndrome, or STSS.

Officially recognized in 1987, STSS is related to the strain of streptococcus called the flesh-eating bacterium. STSS affects only one or two out of every 100,000 Americans. It almost never follows a simple strep throat infection.

In Europe and the United Kingdom, however, the incidence of streptococcal toxic shock syndrome has continued to rise through the 1990s. In one district in the United Kingdom, the annual rate rose from 1.1 cases per million population in 1990 to 9.5 cases per million by 1999. The fatality rate is 64%, even in healthy young adults.

Causes and symptoms


STSS is caused by a strain of Streptococcus pyogenes found in the nose, mouth, and occasionally the vagina. The bacteria produce a characteristic toxin. In large enough quantities, the toxin can enter the blood-stream, causing a potentially fatal infection.

While experts know the name of the bacterium, more than 10 years after the 1980s epidemic scientists still do not fully understand the link between TSS and tampons. Most medical researchers today suspect that the absorbent tampons introduce oxygen into the vagina, which is normally an oxygen-free area of the body.

Oxygen triggers bacterial growth, and the more absorbent the tampon, the more bacteria it can harbor. Some experts believe that the reason TSS is linked to tampons in particular is that bacteria can contaminate and multiply in a tampon.

If left in place for a long time—as a woman could do with a super absorbent product—the bacteria have a better chance of multiplying and producing a large amount of toxin. It is also possible that the tampons or the chemicals they contain may irritate the vaginal lining, enabling the toxin to enter the bloodstream.

These type of bacteria are normally present either on hands or in the vagina, and it takes an amount of bacteria only the size of a grain of sand to start an infection. Of the 15% of women who carry Staphylococcus aureus, only about 5% have the strain that produces the TSS toxin.


TSS. TSS begins suddenly, with a high fever of 102°F (38.9°C) or above, vomiting and watery diarrhea, headache, and sunburn-like rash; together with a sore throat and body aches.

Blood pressure may plummet a day or two after the first symptoms appear. When the blood pressure drops, a woman may become disoriented or go into shock and her kidneys may fail. After these developments, the skin on her hands and feet may peel.

STSS. STSS can occur after a streptococcal infection in the body, usually from an infected wound or even chickenpox. Typically, within 48-96 hours, the patient’s blood pressure drops.

There is also fever, dizziness, breathing problems, and a weak, rapid pulse. The area around the wound may swell, the liver and kidneys can fail, and bleeding problems may occur.


Any woman who is wearing a tampon and begins to experience the symptoms of toxic shock syndrome should remove the tampon right away and seek medical care.

The doctor will probably examine the vagina for signs of inflammation and rule out common sexually transmitted diseases with similar symptoms. A variety of blood tests, tests of vaginal secretions, and a physical examination are needed to identify this condition.


Toxic shock syndrome is a life-threatening condition. If it is suspected, emergency medical attention should be sought immediately. Treatment with antibiotic drugs and IV fluids will be necessary.

Goldenseal, calendula, and echinacea can be applied topically. A diet low in sugar, with an increase in the consumption of vegetables and fruit helps to build the immune system. Movement therapies and exercise are also beneficial.

Allopathic treatment


In a menstruating woman, the vagina is first cleansed with an antiseptic solution to eliminate some of the bacteria that produce the toxin. TSS is treated with antibiotics, together with other drugs and fluids to lower fever and control blood pressure.



Antibiotics are used to treat STSS. Surgery may be needed to remove dead skin and muscle.

Expected results

TSS lasts as long as three weeks, and may have a tendency to recur. About a third of the women who are treated for TSS have it again within six months. In addition, TSS can affect the liver, kidneys, lungs, and other organs, depending on the severity of the infection. Untreated toxic shock syndrome can be fatal.



Women who wear tampons should change them often and use different brands and types of pads and tampons. If a woman really prefers tampons, experts recommend using the lowest possible absorbency product made of cotton and rayon, and wearing it only during the day. In the past, it was difficult to compare absorbency rates for different products.

Today, the Food and Drug Administration (FDA) requires standardized absorbency measurements on all tampon boxes. Above all, women should wash their hands before inserting a tampon, and change the tampon every four to six hours.

Anyone who has had TSS even once should not use tampons again.


Doctors still are not sure how people can avoid STSS, but they advise patients to clean and bandage open wounds immediately. Anyone with a red, swollen, or tender wound, or a sudden fever should seek medical care.