Toxic Shock Syndrome (TSS): Everything You Need To Know

Medically Reviewed By Michaela Murphy, PA-C
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Toxic shock syndrome is a life threatening response to a bacterial infection. The bacteria release toxins, possibly leading to rapid organ failure, shock, and even death. Toxic shock syndrome (TSS) can be fatal without diagnosis and treatment. However, with treatment, many people can make a full recovery.

TSS is most commonly associated with extended and super absorbency tampons. Since many of those types of tampons are no longer on the market, cases of tampon-associated TSS have decreased.

This article will provide more information about TSS, what causes it, and what happens in the body with TSS. It also describes the symptoms TSS can cause, how you can prevent it, and how doctors treat it.

What is toxic shock syndrome?

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Lucas Ottone/Stocksy United

Toxic shock syndrome (TSS) is a dangerous reaction in the body to a bacterial infection. Most often, TSS comes from Staphylococcus aureus. This bacteria is also called strep A, group A Streptococcus (GAS), and Streptococcus pyogenes

The Centers for Disease Control and Prevention (CDC) explains that any strep A infection can develop into TSS, or Streptococcal Toxic Shock Syndrome (STSS). 

TSS occurs when bacteria enter the body’s deep tissues and eventually into the bloodstream. These bacteria can produce toxins. The presence of bacteria and toxins in the deep tissue and bloodstream causes a body response called a cytokine cascade. This cytokine cascade is the result of an overactive immune system.

A cytokine cascade can lead to TSS symptoms, including shock and multiple organ system failures.

Who gets it?

According to the CDC, anyone can get TSS. However, the disorder seems to occur more often in:

  • winter months
  • developing countries
  • people whose initial infections were on the skin
  • the very young and elderly 
  • people with diabetes

TSS was famously associated with a certain brand of tampons in the 70s and 80s. However, those tampons are no longer available for sale

Using tampons will not give you TSS. However, the risk of TSS can increase if you use tampons incorrectly. For example, not changing your tampon regularly or only using super-absorbent tampons for extended periods.

Is it rare?

TSS is rare. Researchers estimate that only about 0.8–3.4 per 100,000 people develop TSS annually in the United States. This statistic includes both tampon-associated and non-tampon-associated cases of TSS.   

Is it fatal? 

According to the CDC, TSS from strep A can be fatal, and mortality rates are high. Anywhere from 3–7 people out of every 10 who develop TSS die due to the condition. 

Prompt recognition of symptoms and treatment will generally help increase survival rates with TSS. 

What are the symptoms of toxic shock syndrome? 

Toxic shock syndrome (TSS) generally develops in two phases, with early and late symptoms occurring. 

The early symptoms of TSS include

  • sudden, high fever
  • chills
  • achy muscles all over the body
  • nausea and vomiting

The later symptoms of TSS will develop very quickly, typically within 24–48 hours. Later symptoms of TSS indicate that the condition h

The later symptoms of TSS include: 

  • low blood pressure
  • rapid heart rate
  • rapid breathing 
  • organ failure that typically involves 3 or more organ systems, including kidney and liver systems
  • skin rash that can look like a sunburn across the majority of the body
  • shedding of the skin of the palms and soles of the feet

How long do symptoms take to appear? 

According to the CDC, exactly when symptoms of TSS appear depends on where in the body the bacteria enter. 

Once the early symptoms of TSS appear, the severe symptoms will develop within 12–48 hours. The condition can progress faster in children.

When to contact a doctor 

You should always contact a doctor if you develop toxic shock syndrome (TSS) symptoms. This is especially true if you have had a recent infection, surgery, regularly use tampons incorrectly, or have a skin injury.

TSS is a medical emergency, and prompt treatment is necessary to help increase the chances of recovering. 

What causes toxic shock syndrome? 

The CDC explains that toxic shock syndrome (TSS) occurs due to a bacterial infection, typically from strep A. The condition can develop when the bacteria enter the body, although it is rare.

Bacteria enter the body either through a break in the skin, such as injury, or through mucous membranes.

According to the CDC, the main areas where bacteria enter the body in cases of TSS include: 

  • the vagina, which is why tampon use can introduce the bacteria
  • the pharynx, or the nasal passages
  • mucosa
  • skin and soft tissue

There has been a decrease in vaginal-implicated TSS since particular brands of tampons in the 70s and 80s ceased production.

The CDC also notes that in up to 50% of cases, it is unclear how the bacteria entered the body.

What are the risk factors of toxic shock syndrome? 

The CDC explains that anyone can get toxic shock syndrome (TSS). However, some risk factors are associated with increased incidences of the condition. 

These include:

  • being 65 years old or over
  • having an open wound or another type of break in the skin
  • having a recent surgical procedure
  • having a recent viral infection that causes open sores on the skin, such as chickenpox
  • having a chronic illness, especially diabetes and alcohol use disorder 
  • not using tampons correctly, such as using tampons for prolonged periods
  • not having sufficient hygiene, especially if you have other risk factors
  • having a recent birth, miscarriage, or abortion
  • using contraceptive sponges or diaphragms
  • having a history of TSS
  • experiencing recent physical trauma, even without breakages in skin

What is the survival rate for toxic shock syndrome?

The CDC notes that toxic shock syndrome (TSS) resulting from strep A can have a mortality rate of 30–70%

That means that the survival rate for severe cases of STSS can be as high as 70%. Children tend to have higher survival rates than older adults. Additionally, the death rate from TSS has decreased over the past 2 decades. This is because awareness and prompt treatment of the condition have grown. 

How do you treat toxic shock syndrome? 

Toxic shock syndrome (TSS) is always a serious, life threatening condition that will require treatment in a hospital. With treatment, the condition can resolve. 

The CDC explains that TSS treatments will include

  • antibiotic therapy administered through an IV
  • IV fluids to rehydrate the patient
  • removal of any infected sources, if possible 
  • oxygen support, if needed

The CDC also notes that doctors may use immunoglobulin given through an IV to treat severe TSS. However, that form of therapy still needs more evidence to prove it is effective.

What are the complications of toxic shock syndrome?

The complications of toxic shock syndrome (TSS) can be very serious. Aside from death, the complications of TSS can include

  • multiple organ failure
  • shock
  • necrosis, which is tissue death
  • loss of extremities 
  • extreme scarring

How do doctors diagnose toxic shock syndrome? 

Doctors will admit anyone with suspected toxic shock syndrome (TSS) to the hospital for further testing. There is not one single test that will diagnose TSS. Instead, a medical team will use several diagnostic tools to identify TSS. 

In general, a healthcare professional will use the following to diagnose TSS:

  • physical exam, including heart rate, breathing rate, and temperature
  • bloodwork, including blood cultures to look for a bacterial cause
  • CT scan to evaluate bruising, skin breakdown, or hot and swollen joints
  • chest X-ray

Doctors will diagnose TSS if there are signs of low blood pressure and evidence of impact on multiple organ systems. The involvement of multiple organs, common symptoms, and shock may suggest TSS. Blood culture findings can confirm this diagnosis and help begin prompt treatment.

TSS may affect various organs and systems, including:

  • kidneys
  • blood
  • liver
  • lungs
  • skin

How can you prevent toxic shock syndrome? 

There is no vaccine to prevent toxic shock syndrome (TSS). According to the CDC, good hygiene and wound care protection are the best ways to prevent TSS. 

To help prevent TSS, you should: 

  • Use low absorbency tampons and change them regularly.
  • Wash hands before and after inserting the tampon.
  • Clean all breaks in the skin, including cuts, injuries, and blisters, with soap and water.
  • Cover any open wounds with clean, dry bandages until they heal.
  • Have a doctor assess any deep wounds.
  • Avoid pools, hot tubs, and natural bodies of water if you have an open wound or active infection.
  • Wash your hands regularly. 
  • Dispose of used tissues properly and avoid sneezing into your hands.

The CDC also notes that TSS is very rarely contagious. However, the bacteria that cause TSS can spread easily.

Frequently asked questions 

Here are some frequently asked questions about toxic shock syndrome (TSS).

How do I know if I have toxic shock syndrome? 

If you develop a sunburn-like rash on your hands and the bottom of your feet, a high fever, dizziness, nausea, or vomiting, seek medical attention immediately.

Can you get toxic shock syndrome from menstrual cups? 

Because bacteria cause TSS, a menstrual cup without proper sanitation could be a potential source of infection. There has been a documented case of TSS from menstrual cup use. 

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

Tampons do not cause TSS. A bacterial infection causes TSS. Anytime you do not change tampons regularly or use them as indicated, it could pose a risk for infection. If you do develop TSS after an infection, it can take weeks after the initial infection for TSS symptoms to appear.

Summary 

Toxic shock syndrome (TSS) is a life threatening condition marked by low blood pressure, a high fever, and multiple organ failure. It can have a mortality rate as high as 70%, although survival rates increase with prompt treatment. Early symptoms include nausea, vomiting, muscle aches, and fever. However, more serious symptoms, such as low blood pressure, will begin within 12–48 hours.

TSS most often occurs due to an infection of strep A bacteria that enters the body through an open break in the skin or the mucosa.

Anyone can get TSS. However, certain factors can increase the risk. TSS is more likely in people who are very young or elderly or use products such as tampons or barrier contraceptives in the vagina. People who have had a recent infection, surgery, birth, miscarriage, or abortion are also at a higher risk. 

Anyone who suddenly develops symptoms of TSS, such as high fever, low blood pressure, and vomiting, should seek emergency medical attention. 

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Medical Reviewer: Michaela Murphy, PA-C
Last Review Date: 2022 Jun 15
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THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
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