Warning: If you show signs of toxic shock syndrome including fever, vomiting, low blood pressure, or a sunburn-like rash, particularly during menstruation and tampon use or if you have had a recent surgery, we advise you to seek immediate medical attention.

Toxic shock syndrome (TSS) is a rare, life-threatening complication of certain types of bacterial infections. Often this condition results from toxins produced by Staphylococcus aureus (commonly known as staph) bacteria, but toxic shock syndrome may also be caused by toxins produced by group A streptococcus (commonly known as strep) bacteria. ¹ Toxic shock syndrome is often associated with the use of superabsorbent tampons; however, this condition can also affect children, men and post-menopausal women. Risk factors for toxic shock syndrome include the use of tampons, menstrual cups, and diaphragms, as well as recent skin wounds and surgery.²

Symptoms

Toxic shock syndrome is characterized by rashes, hypotension (low blood pressure), and multi-organ disfunction.³ It is common for a sunburn-like rash to appear within a few hours of toxic shock syndrome. The rash, which may lead to peeling skin, most commonly appears on the palms of the hands and soles of the feet.⁴ Toxic shock syndrome may mimic other diseases and can become lethal if it is not recognized and treated appropriately. People experiencing toxic shock syndrome may experience the following symptoms: 

• A sudden high fever
• Low blood pressure 
• Vomiting or diarrhea 
• A rash resembling a sunburn, particularly on one’s palms and soles
• Muscle aches
• Headache or lightheadedness 
• Redness of the eyes, mouth, and throat 
• Seizures

If an individual is experiencing any of these symptoms, especially while menstruating, they should remove any menstrual products in use and seek medical attention immediately. Treatment for toxic shock syndrome includes intravenous fluids, source control, and antibiotics.⁵

Causes and Risk Factors

The most common cause of toxic shock syndrome is infection with the Staphylococcus aureus (staph) bacteria. This bacterium is often found during the prolonged use of a tampon or other menstrual product inserted into the vagina. Infection from staph bacteria occurs due to the production of toxins in a blood-soaked tampon. A tampon soaked in blood grows bacteria at a rapid rate. Subsequently, the bacteria can get through small abrasions in the vaginal lining or uterus and flow into the bloodstream. ⁶

Certain tampons are more likely to cause toxic shock syndrome. Tampons made from polyester foam grow bacteria more rapidly as opposed to tampons made from cotton or rayon fibers. Vaginal tears, which are often microscopic and cannot be felt, are more likely to occur with the use of a superabsorbent tampon used during a light menstrual flow, or simply by being left in the vagina for an extended period of time.⁷ 

Although toxic shock syndrome is most closely associated with the use of tampons, it may occur in people without vulvas or people who do not use tampons. The condition may occur with the use of diaphragms, cervical caps, and menstrual sponges, as well as individuals who have fresh cuts or burns, had recent surgery, or had a viral infection such as the flu or chickenpox.⁸ 

Diagnoses and Treatment

The diagnosis of toxic shock syndrome is considered probable if three or more of the below criteria are met in association with peeling skin, or if five or more criteria are met in the absence of peeling skin. The criteria include fever, rash, low blood pressure, and the involvement of three or more organ system issues.⁹

Individuals with toxic shock syndrome should be immediately hospitalized as intensive treatment will often be necessary. Management of the condition requires intravenous fluid, antibiotics, and electrolyte replacement in addition to a vaginal examination for individuals with vulvas.¹⁰

Concluding Remarks

Toxic shock syndrome is a potentially deadly condition if left untreated. While toxic shock syndrome is related to the overuse of certain types of tampons, manufacturers of tampons sold in the United States no longer use the materials or designs that are associated with toxic shock syndrome. The U.S. Food and Drug Administration requires manufacturers to use standard measurement and labeling for absorbency and to print guidelines on the boxes. In order to avoid toxic shock syndrome, tampon users should read tampon labels and use the lowest absorbency tampon required for their menstrual flow. In addition, tampons should be changed every four to eight hours to prevent overgrowth of bacteria.¹¹It should be noted that toxic shock syndrome can reoccur; therefore, individuals who have previously had toxic shock syndrome or a serious staph/strep infection should discontinue their use of tampons. 

References

1. Mayo Foundation for Medical Education and Research. (2020, March 18). Toxic shock syndrome. Mayo Clinic. 
2. Mayo Foundation for Medical Education and Research. (2020, March 18). Toxic shock syndrome. Mayo Clinic. 
3. Prevalence, comorbidities and mortality of toxic shock syndrome in children and adults in the USA. Microbiology and immunology
4. Mayo Foundation for Medical Education and Research. (2020, March 18). Toxic shock syndrome. Mayo Clinic. 
5. Gottlieb, M., Long, B., & Koyfman , A. (2018, June 1). The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. The Journal of Emergency Medicine. 
6. Mayo Foundation for Medical Education and Research. (2020, March 18). Toxic shock syndrome. Mayo Clinic. 
7. Toxic shock syndrome. NORD (National Organization for Rare Disorders). (n.d.). 
8. Toxic shock syndrome. NORD (National Organization for Rare Disorders). (n.d.). 
9. Toxic shock syndrome. NORD (National Organization for Rare Disorders). (n.d.). 
10. Gottlieb, M., Long, B., & Koyfman , A. (2018, June 1). The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. The Journal of Emergency Medicine. 
11. Mayo Foundation for Medical Education and Research. (2020, March 18). Toxic shock syndrome. Mayo Clinic. 

Last updated: 3 March 2022