Toxic shock syndrome (TSS)

Toxic shock syndrome is rare, but few conditions move as fast: someone can be well in the morning and in intensive care by the evening. The damage comes not from the infection itself but from toxins released by certain bacteria, which act on the whole body at once and drop the blood pressure. The syndrome is best known for its link with tampons, yet it is far from limited to them, and about half of all cases have nothing to do with periods at all. Men and children get it too. The one thing that genuinely decides the outcome is how quickly the person reaches hospital.

What it looks like

TSS starts abruptly and at first resembles a very heavy bout of flu. What sets it apart is the combination of signs and the speed at which they build — over hours, not over a week.

• a sudden high temperature, often with shivering;
• a rash like sunburn: continuous redness of the skin over the whole body, palms and soles included, usually flat and not itchy;
• vomiting and diarrhoea starting almost at the same time as the fever;
• severe aching and muscle pain, with weakness that makes standing hard;
• dizziness, vision going dark on standing, fainting — that is the blood pressure falling;
• confusion, odd behaviour, slurred speech;
• headache, sore throat, redness of the eyes, the tongue and the lining of the mouth.

Later, usually one to two weeks after the illness begins, the skin of the palms and soles starts peeling away in sheets. That is a late sign: it confirms the diagnosis, but waiting for it is out of the question.

One separate thing worth remembering concerns wounds. When TSS is caused by a streptococcus, the earliest and most important warning is often pain at a wound or in a muscle that is out of all proportion to how the area looks. The wound can appear trivial while the pain is unbearable; that means going to hospital immediately.

When to call an ambulance

Call an ambulance straight away (across Europe the emergency number is 112) if a high temperature comes with any of the following: a widespread rash like sunburn, vomiting and diarrhoea alongside the fever, dizziness or fainting, confusion, very severe pain in a muscle or a wound, passing no urine for many hours, blue or mottled skin and lips, rapid breathing.

What to do while help is on its way:

• if a tampon, menstrual cup, cap or diaphragm is in place, take it out at once and bring it with you;
• do not drive yourself and do not wait for morning;
• tell the clinicians immediately about the tampon or cup, or about a recent wound, burn, operation, birth or caesarean — it changes the course of the assessment from the first minute;
• bring a list of the medicines you take;
• if this is a child who is becoming steadily sleepier, is hard to rouse, refuses to drink, or has cold hands and feet alongside a high temperature, that too is an ambulance without delay.

Do not bring the temperature down and wait to see what happens: in TSS the interval between feeling unwell and being critically unwell is measured in hours.

Where it comes from

The bacteria behind the syndrome are ordinary inhabitants of skin, nose and mucous membranes, and in most people they cause no harm at all. Trouble starts when they find the right conditions, multiply and release the toxin while the person has no antibodies against it. The usual settings are:

• tampons and menstrual cups, particularly ones left in for a long time;
• barrier contraception that sits inside: caps, diaphragms, sponges;
• vaginal birth and caesarean section, and any infection of the womb after delivery;
• burns, including small ones;
• cuts, grazes, bites, boils and any wound that has become infected;
• surgical wounds, which from the outside sometimes look entirely settled;
• nasal packing after surgery or a nosebleed;
• in children, chickenpox spots that have been scratched.

Because of the history with tampons, the idea has stuck that TSS is a "women's illness". It is not: a substantial share of cases arises from wounds and burns, and therefore in people of any sex and any age.

Tampons and cups: keeping the risk down

There is no need to give up tampons over the risk of TSS, which is very small. But a handful of rules make it smaller still, and all of them come down to one thing: giving the bacteria neither time nor conditions.

• Use the lowest absorbency that copes with your flow on that particular day. A tampon chosen "to be on the safe side" sits inside dry and for longer.
• Change it regularly, going by the instructions on the packet rather than by a feeling that it is still fine.
• Overnight a pad is the safer choice. If you do use a tampon, do not leave it in longer than the manufacturer states and put it in right before bed.
• Wash your hands before and after inserting one, and never use two at once.
• Alternate tampons with pads through the period.
• Remember to remove the last tampon at the end of the period — a forgotten tampon is commoner than people assume.
• Clean and treat a menstrual cup exactly as its instructions say, and empty it within the stated interval.
• If you feel unwell during a period, take the tampon out at once, without waiting for the end of the day, and seek help. Tell the doctor you had been using a tampon: without that sentence the diagnosis comes later.

Wounds, burns and stitches

From this side TSS creeps up more quietly, because nobody thinks to suspect the wound.

Wash cuts and grazes and keep them clean and covered. A burn, even a small one, is cooled under running water and the blisters are left unbroken. Watch any wound, a surgical one included, for several days: what should worry you is pain that keeps increasing, redness spreading outwards, swelling, discharge with a smell and, above all, a general deterioration with fever, shivering and weakness that does not match the look of the wound.

See a doctor the same day if a wound has become inflamed or you feel worse after an operation or a birth. Call an ambulance if a rash, vomiting, confusion, dizziness or unbearable pain is added to that. The same applies after childbirth: fever, shivering and sudden severe weakness in the first weeks are always a reason to contact a doctor at once, not to wait for the planned check.

What happens in hospital

TSS is treated only as an inpatient, often straight in intensive care, because the main job is to hold up the blood pressure and support the organs while the antibiotic takes effect.

• intravenous fluids, sometimes in very large volumes: in TSS fluid leaks out of the vessels into the tissues;
• intravenous antibiotics, usually a combination, including ones that suppress toxin production;
• medicines to support blood pressure;
• oxygen, and in severe cases ventilator support;
• dealing with the source: removing the tampon or cup, washing out and surgically cleaning the wound, sometimes more than once;
• intravenous immunoglobulin in selected cases;
• temporary dialysis if the kidneys fail.

Blood tests and cultures are taken immediately, but treatment starts without waiting for the results: there is no room here for waiting on confirmation. Started in time, most people recover, though recovery takes weeks.

Afterwards: it can happen again

Having had TSS leaves no reliable immunity — on the contrary, anyone who has had it carries a higher risk of a second episode than everyone else. So after menstrual TSS tampons are not used again, and caps, diaphragms and sponges are usually advised against as well. Pads and other methods of contraception remain, and which of them suits is worth working out with a doctor.

Recovery is gradual. The skin of the palms and soles peels over several weeks, and a month or two later hair may shed and nails may come away — unpleasant, but it settles on its own. Weakness and tiring easily last longest, sometimes for several months. If after discharge the fever returns, a new rash appears or things suddenly get worse again, that needs medical attention immediately.

Online consultation

Toxic shock syndrome is neither treated nor confirmed online: a suspicion of it needs an ambulance, and no message replaces that. What does work remotely are the questions around it. The doctor can weigh up whether your illness really resembles TSS or a more ordinary infection, explain which signs to watch on a healing wound, a burn or a line of stitches, help sort out how tampons and cups should be used, and — if an episode has already happened — work out which hygiene products and contraception are open to you now. Everything set out in the ambulance section above is not assessed remotely: with that you call for help at once.

This material is for information only and does not replace medical advice.