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Toxic Shock Syndrome (TSS): Symptoms, Causes, and Emergency Response

What Is TSS?

TSS is a rare, life-threatening toxin-mediated illness caused by Staphylococcus aureus (staphylococcal TSS) or Streptococcus pyogenes (streptococcal TSS/TSLS). Superantigen toxins (TSST-1, enterotoxins) trigger massive cytokine release → capillary leak, hypotension, multi-organ failure.

Classic Staphylococcal TSS (Menstrual & Non-Menstrual)

CDC Case Definition requires:

  1. Fever ≥38.9°C (102°F)
  2. Rash: diffuse macular erythroderma (sunburn-like), desquamates 1–2 weeks later
  3. Hypotension: SBP ≤90 mmHg (adults) or orthostatic drop ≥15 mmHg
  4. Multi-system involvement (≥3): GI (vomiting, diarrhea), muscular (myalgia, CK↑), mucous membrane (conjunctival/oral/vaginal hyperemia), renal (Cr↑), hepatic (ALT/AST↑), hematologic (platelets↓), CNS (confusion)

Additional Common Symptoms

  • Sudden onset, flu-like prodrome
  • Confusion, dizziness, syncope
  • Tachycardia out of proportion to fever
  • Non-purulent conjunctivitis, strawberry tongue
  • Edema (hands/feet)

Risk Factors

  • Super-absorbent tampons (especially prolonged use >8 hrs)
  • Contraceptive sponges, diaphragms, menstrual cups
  • Post-surgical, postpartum, or wound infections
  • Burns, skin infections, nasal packing

Streptococcal TSS (STSS)

Often follows varicella, skin/soft tissue infection, or surgery. More severe: necrotizing fasciitis, myonecrosis, higher mortality (30–60%).

Emergency Management

  1. Recognize early: High index of suspicion in febrile, hypotensive patient with rash + tampon/wound.
  2. Remove source: Tampon, packing, drain abscess.
  3. Aggressive fluid resuscitation (crystalloids, then vasopressors).
  4. Empiric antibiotics: Vancomycin + clindamycin (clindamycin inhibits toxin synthesis) ± beta-lactam for strep coverage.
  5. IVIG (1–2 g/kg) considered for refractory staphylococcal TSS.
  6. ICU monitoring for organ support.

Prevention

  • Use lowest absorbency tampon; change ≤8 hrs; alternate with pads.
  • Wash hands before/after insertion.
  • Don’t use tampons when not menstruating.
  • Prompt wound care; seek care for spreading redness/fever.

TSS is a medical emergency. Call 911 or go to ER immediately if suspected.

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