The causes of toxic shock syndrome (TSS) are not fully understood, although several risk factors have been identified.

Bacteria

The bacteria involved in TSS – Staphylococcus aureus and Streptococcus pyogenes – can be found on the skin and in the nose or throat of healthy individuals, where they usually cause no serious problems.

Most people have toxin-fighting proteins known as antibodies, which can protect the body against these toxins. However, for reasons that are unknown, a small percentage of people do not develop these specific antibodies.

What is known is that the bacteria can enter the body through a wound, burn, the throat or the vagina. They release toxins into the bloodstream. These toxins cause inflammation, interfering with the processes that regulate blood pressure and causing it to drop to a dangerously low level. This results in multiple organ failure, usually affecting the kidney. The bacteria also attack tissues, including the skin, muscles and organs.

Risk factors

The following factors are thought to increase the risk of toxic shock syndrome:

• a woman being on her period – especially if she leaves a tampon in for a long time (see below)
• using female barrier contraceptives, such as a contraceptive diaphragm
• developing a wound infection after having surgery
• having a staphylococcal infection or streptococcal infection
• using nasal packing to treat a nosebleed 
• having a baby
• having a skin wound such as a cut, burn or recent chickenpox

Tampons

The role of tampons in TSS remains unexplained. One theory is that if a tampon is left in your vagina for some time, as is often the case with the more absorbent types of tampons, it can become a breeding ground for the bacteria.

Another theory is that the fibres of the tampon may scratch your vagina, allowing the bacteria or the toxins to enter the blood.

No evidence has been found to support either theory.

Toxic shock syndrome (TSS) is a rare but life-threatening bacterial infection caused by Staphylococcus aureus and Streptococcus pyogenes bacteria.

These bacteria normally live harmlessly on the skin, nose or mouth but can invade the body’s bloodstream and release poisonous toxins.

The toxins also damage tissue, including skin and organs, and can disturb many vital organ functions.

Read more about the symptoms of TSS.

What to do

TSS is a medical emergency and you should see your GP as soon as possible if you have any of the symptoms of TSS.

If your GP suspects you have TSS, you’ll be referred to hospital immediately and may be treated in an intensive care unit. The goal is to fight the infection with antibiotics and support any functions of the body that have been affected.

Read more about the treatment of TSS.

How is toxic shock syndrome diagnosed?

There is no single test for toxic shock syndrome (TSS). The condition is diagnosed by looking for the typical symptoms and checking for evidence of organ failure.

Organ function can be tested in a variety of ways, including blood and urine tests.

A confident diagnosis of TSS can usually be made when:

• you have a temperature of 38.9C (102F) or above
• you have low blood pressure, fainting and dizziness
• you have a widespread, flat, red skin rash
• three or more of your organs have been affected by infection
• an infection caused by staphylococcus or streptococcus is apparent or likely

If all of the above are present, it is likely that you have TSS.

Who is at risk?

Anyone can get TSS – men, women and children.

For reasons that are still not understood, a significant proportion of cases occur in women who are on their period and using a tampon, particularly tampons that are designed to be ‘super absorbent’.

TSS can also occur as a result of an infected boil, insect bite or wound, for example. Some cases are associated with skin damage from a burn or scald, which allows the bacteria to enter the body and release toxins.

Find out more about the causes of TSS.

The risk of TSS is greater in young people. It is thought that this is because many older people have developed immunity (resistance) to the toxins produced by the bacteria.

Outlook

TSS is a serious, life-threatening condition. If left untreated, the combination of shock and organ damage can result in death – especially if the infection was caused by streptococcus bacteria.

If TSS is diagnosed and treated early with antibiotics, there is a good chance of recovery, and improvement is usually shown within 48 hours. However, TSS associated with streptococcus can be severe and rapidly progess to organ failure.

The condition can also reoccur in those who recover.

The best way to prevent toxic shock syndrome (TSS) is to get quick treatment for wounds on the body and correctly use tampons and contraception.

Read information about:

• first aid
• how to clean a wound
• treating burns and scalds

Care when using tampons

The link between TSS and tampon use is unclear, but research suggests that tampon absorbency may be a factor. For this reason, it is important that you:

• always use a tampon with the lowest absorbency suitable for your period flow
• alternate tampons with a sanitary towel or panty liners during your period

You should also remember to:

• wash your hands before and after inserting a tampon
• change tampons regularly – as often as directed on the pack
• never insert more than one tampon at a time
• when using one at night, insert a fresh tampon before going to bed and remove it on waking
• remove a tampon at the end of a period

Information about TSS is contained in the tampon manufacturer’s instruction leaflet. This information is often updated, so it is important to read the leaflet regularly.

TSS has been known to recur, so avoid using tampons if you have had TSS before.

Female barrier contraception

If you are using a female barrier form of contraception, such as a diaphragm, contraceptive cap or sponge, always follow the manufacturer’s instructions about how long you can leave the device in your vagina. If these devices are left in for too long, they could cause an infection and potentially TSS.

If you have had TSS in the past, you may wish to use an alternative method of contraception.

The symptoms of toxic shock syndrome (TSS) normally begin with a sudden high fever (body temperature rises above 38.9C/102F).

Other symptoms then rapidly develop, normally in the course of a few hours. They may include:

• flu-like symptoms including headache, muscle aches, sore throat and cough
• nausea and vomiting
• diarrhoea 
• fainting or feeling faint
• dizziness or confusion

A widespread sunburn-like skin rash may also occur, with the whites of the eyes, lips and tongue becoming more red than usual.

One or two weeks after the rash appears, it is common that the skin begins to shed in large sheets, especially from the palms of the hands and soles of the feet.

People with streptococcal TSS may also have the symptoms of a serious streptococcal infection. For example, pain in the muscles, abdominal pain (such as after childbirth) or cough.

When to seek medical advice

If you develop a sudden fever and one or more of the other symptoms listed above, it is still extremely unlikely that you have TSS. However, symptoms like these should never be ignored. Contact your GP, local out-of-hours service or NHS 111 immediately.

If you are wearing a tampon, remove it straight away. Also tell your GP or doctor if you have been using a tampon, recently suffered a burn or skin injury, or if you have a skin infection such as a boil or a blister that has become infected.

If you have toxic shock syndrome (TSS) you will need to be admitted to hospital straight away and may need to be treated in an intensive care unit.

Most people will respond to treatment within a couple of days, but it may take several weeks before they are well enough to leave hospital.

There are two important goals in the treatment of toxic shock syndrome (TSS):

• treating the infection
• supporting any functions of the body that have been affected

Treating infection

The infection can normally be treated by a combination of antibiotics, which are given directly into the bloodstream via a drip (intravenously).

In some cases, immunoglobulin may also be given as well as antibiotics. Immunoglobulin is a sample of donated human blood known to contain a high level of antibodies, which can be used to fight the toxins produced by the bacteria.

Supporting the body

The following treatments may be needed in hospital to help stupport bodily functions:

• oxygen – to support breathing
• fluids – to help prevent dehydration and organ damage
• medication – to help control blood pressure
• dialysis – if the kidneys stop functioning, a dialysis machine is used to filter the blood

You may need to stay in the intensive care unit for monitoring.

Cleaning infected tissue

If the bacteria or toxins have damaged parts of the skin, or other extremities of the body such as the fingers or toes, the infected tissue will need to be drained and cleaned.

In extreme cases, it may be necessary to surgically remove parts of the skin or amputate (remove by surgery) an extremity of the body.