Toxic Shock Syndrome

Overview

What is toxic shock syndrome (TSS)?

Toxic shock syndrome (TSS) is a rare but potentially life-threatening condition caused by certain strains of bacteria that produce poisons (toxins). These toxins get into your bloodstream and can affect organs such as your heart, liver or kidneys. It's often associated with using tampons during menstruation. However, TSS can affect anyone of any age. Skin wounds, surgical incisions, nasal packing, scrapes, burns or other areas of injured skin can increase the risk of the condition. Half of all cases are unrelated to menstruation.

The symptoms of TSS happen suddenly and worsen quickly. However, most people recover if TSS is diagnosed and treated quickly.

How common is toxic shock syndrome (TSS)?

Toxic shock syndrome affects 1 in every 100,000 people. TSS is more common in people assigned female at birth (AFAB), but it can affect anyone. Until the 1990s, it was most commonly associated with people using super-absorbent tampons during their period.

Symptoms and Causes

What are the symptoms of toxic shock syndrome (TSS)?

Symptoms of toxic shock syndrome may vary depending on the type of bacteria producing the toxins. They may include:

  • Sudden high fever, chills, body aches and other flu-like symptoms.
  • Nausea or vomiting.
  • Watery diarrhea.
  • Rash resembling a bad sunburn or red dots on your skin.
  • Dizziness, lightheadedness or fainting.
  • Low blood pressure (hypotension).
  • Redness in your eyes (conjunctivitis) and throat.
  • Peeling of the skin on the soles of your feet or palms of your hands.

What causes toxic shock syndrome (TSS)?

Most cases of toxic shock syndrome are caused by a toxin produced by Staphylococcus aureus (staph infection) and streptococcus pyogenes (group A strep infection). Clostridium sordellii can also cause toxic shock syndrome, but it's less common.

Under normal circumstances, these bacteria live on your skin or on your mucous membranes (like your throat or mouth) without causing any ill effects. However, under certain conditions, some strains of bacteria may start to grow rapidly and produce toxins.

When you use a tampon, Staphylococcus aureus (staph) bacteria may become trapped in your vagina and enter your uterus via your cervix. Bacteria may grow on tampons, especially if they aren’t changed often enough. Bacteria may also grow if your menstrual flow is light and you use a super-absorbent tampon. Tampons can also cause tiny cuts in your vagina, and bacteria can enter your bloodstream.

Leaving a tampon in too long is not the only way to get toxic shock syndrome. Medical experts now know that anything that stays in your vagina for longer than the recommended time can increase your risk for toxic shock syndrome. This includes contraception such as cervical caps, sponges or diaphragms, or menstrual cups (cups used during your period).

Toxic shock syndrome can occur when bacteria gets into open wounds, cuts or sores on your body. This can be from a skin infection, surgery, childbirth or a nosebleed that requires packed gauze to stop it.

What bacteria cause toxic shock syndrome (TSS)?

The following bacteria cause TSS:

  • Staphylococcus aureus (S. aureus or staph): This bacteria typically lives on your body. It can enter your bloodstream through skin wounds and small tears in your vagina while using tampons.
  • Streptococcus pyogenes (S. pyogenes or group A strep): This type of bacteria causes toxic shock syndrome in people who have recently had strep throat, scarlet fever, impetigo or other infections caused by group A strep.
  • Clostridium sordellii (C. sordellii): A bacteria typically found in your vagina enters your uterus during menstruation, childbirth or other gynecological procedures. Intravenous drug use can also cause C. sordellii infection.

How long does it take to get toxic shock from a tampon?

There isn't a set time for when symptoms of TSS start after using a tampon. However, tampons should be removed from your vagina after eight hours to lower your risk of TSS. This doesn't mean you will get TSS if a tampon is left in your vagina longer than eight hours. It means studies have shown that prolonged use of a tampon promotes the production of harmful bacteria.

How long does it take to have symptoms of toxic shock syndrome?

The onset of symptoms is usually sudden. Toxic shock syndrome tends to occur within days of the bacteria invading your bloodstream. This doesn't mean that you will get toxic shock syndrome every time you have staph or strep infection, or that you will get it from leaving a tampon in longer than eight hours.

Can sanitary pads cause toxic shock syndrome?

Yes, you can still get toxic shock syndrome if you wear pads. It's less common, but it can happen. This is because bacteria cause the condition — not the tampon.

Diagnosis and Tests

How is toxic shock syndrome (TSS) diagnosed?

Some of the ways healthcare providers diagnose toxic shock syndrome are:

  • Blood or urine tests to determine what type of bacteria or virus is present.
  • Examine your vagina.
  • Obtain tissue cultures from your vagina, cervix or throat so they can be analyzed for the presence of Staphylococcus or Streptococcus bacteria.
  • Obtain tissue from the wound or infection (for non-menstrual TSS).

If your symptoms are severe or have progressed, your healthcare provider may order these tests to check the health of other organs:

Management and Treatment

How is toxic shock syndrome (TSS) treated?

Treatment typically involves hospitalization due to the potentially life-threatening nature of toxic shock syndrome. First, your healthcare provider will remove any tampons or contraceptive devices from your vagina if that is suspected to be the cause. Then, you'll be given intravenous (IV) fluids and possibly medications to raise your blood pressure if it's low.

The standard treatment for Staphylococcus or Streptococcus infection involves antibiotics through an IV. Antibiotics will help control the growth of bacteria, but they will not eliminate the toxins that have already accumulated in your body.

Treatment for TSS may involve:

  • Antibiotics to treat the infection.
  • Purified antibodies taken from donated blood (known as pooled immunoglobulin) to help your body fight the infection.
  • Oxygen to help with breathing.
  • Fluids to prevent dehydration and organ damage.
  • Medicine to help control blood pressure.
  • Dialysis if your kidneys stop functioning.
  • Surgery to remove dead tissue. Rarely, it may be necessary to amputate the affected area.

What are the complications of toxic shock syndrome if left untreated?

Toxic shock syndrome is serious and life-threatening. Symptoms can progress quickly, and immediate treatment is necessary. Shock, organ failure, amputation of limbs and death can occur if toxic shock syndrome is left untreated.

Can toxic shock syndrome (TSS) go away on its own?

No, toxic shock syndrome won't go away on its own. Prompt treatment is necessary to avoid potentially deadly complications.

Prevention

How can I prevent toxic shock syndrome (TSS)?

You can take steps to lower your risk for toxic shock syndrome. Some of these include:

  • Use sanitary pads instead of tampons during menstrual periods or use pads at night. Switching from tampons to pads every other day or when the menstrual flow is heaviest may also help reduce your risk.
  • Change tampons every four to eight hours. If the flow is heavy, tampons may have to be changed more frequently.
  • Use a tampon with the lowest absorbency required for your flow.
  • Don’t use tampons when you aren’t menstruating.
  • Keep surgical incisions clean to avoid infection. See your healthcare provider if you notice unusual swelling, redness or heat near the wound.
  • Follow directions when using vaginal contraceptives such as sponges, caps or diaphragms.

Toxic shock syndrome is more likely to recur in people who've already had it. You should avoid using tampons during your period if you've recovered from a case of TSS.

What are the risk factors for toxic shock syndrome (TSS)?

Most cases of toxic shock syndrome are associated with the use of highly absorbent tampons. People of childbearing age who use tampons during menstruation are at greater risk of developing it. However, cases of toxic shock syndrome also occur in non-menstruating people. People who have undergone surgery may develop wound infections that result in TSS.

Among people assigned female at birth, other risk factors include childbirth, surgery on your uterus and the use of birth control devices such as diaphragms or contraceptive sponges.

The following can increase your risk of getting TSS:

  • Using tampons — particularly if you leave them in for longer than recommended or you use super-absorbent tampons or menstrual cups.
  • Using barrier contraceptives, such as a diaphragm, cup or sponge.
  • A problem with your skin, such as a cut, burn, boil, insect bite or a wound after surgery.
  • Having a recent surgery, miscarriage or recently giving birth.
  • Using nasal packing to treat a nosebleed.
  • Having a Staphylococcal infection or Streptococcal infection, such as a throat infection, impetigo or cellulitis.

Outlook / Prognosis

What is the survival rate of toxic shock syndrome?

Toxic shock syndrome can lead to death in 30% to 70% of cases. Prompt diagnosis and treatment lead to the best outcomes.

Living With

When should I see my healthcare provider?

Contact your healthcare provider if you have signs of toxic shock syndrome, especially if you use tampons, have a skin wound or recently had surgery.

A note from Cleveland Clinic

Toxic shock syndrome (TSS) is a rare but life-threatening condition caused by an overgrowth of two common bacteria. It causes your body to release toxins that can cause organ failure or death. Once thought to be solely related to tampon use, we now know that anyone of any age can get toxic shock syndrome. The main symptoms of TSS are sudden fever, flu-like symptoms, diarrhea and low blood pressure. Contact your healthcare provider or go to the emergency room if you have any signs of toxic shock syndrome. TSS requires prompt treatment with antibiotics, fluids and medication for the best outcomes.

Last reviewed by a Cleveland Clinic medical professional on 08/12/2022.

References

  • American Academy of Family Physicians. Toxic Shock Syndrome. (https://familydoctor.org/condition/toxic-shock-syndrome/) Accessed 8/17/2022.
  • Centers for Disease Control and Prevention. Streptococcal Toxic Shock Syndrome: All You Need to Know. (https://www.cdc.gov/groupastrep/diseases-public/streptococcal-toxic-shock-syndrome.html) Accessed 8/17/2022.
  • Lin YC, Peterson ML. New insights into the prevention of staphylococcal infections and toxic shock syndrome. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102526/) Expert Rev Clin Pharmacol. 2010;3(6):753-767. Accessed 8/17/2022.
  • National Health Service. Toxic shock syndrome. (https://www.nhs.uk/conditions/toxic-shock-syndrome/) Accessed 8/17/2022.
  • National Organization for Rare Disorders. Toxic Shock Syndrome. (https://rarediseases.org/rare-diseases/toxic-shock-syndrome/) Accessed 8/17/2022.
  • Ross A, Shoff HW. Toxic Shock Syndrome. (https://www.ncbi.nlm.nih.gov/books/NBK459345/) [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Accessed 8/17/2022.
  • U.S. Department of Health & Human Services, Office on Women's Health. Your menstrual cycle. (https://www.womenshealth.gov/menstrual-cycle/your-menstrual-cycle) Accessed 8/17/2022.

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