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TOXIC SHOCK SYNDROME

by Mr David Abramovich MB, FRCOG, Consultant Gynaecologist, Aberdeen Royal Infirmary, Aberdeen, Scotland

Toxic shock syndrome is a rare and serious disease that can affect men, women and children. Around 50% of cases occur in menstruating women who are using tampons. It is this latter fact that has prompted alarmist media reports.

Nature and cause

Toxic shock syndrome usually presents with influenza-like symptoms. Most cases of toxic shock syndrome are caused by a strain of Staphylococcus aureus that produces a toxin that is called toxic shock syndrome toxin-1 (TSST-1). Staph. aureus is intermittently present in 10 to 30% of the population, being found on the skin, the fingers, the groin, axilla and the vagina. 10 to 20% of its strains produce TSST-1.

Toxic shock syndrome is rare because 80 to 90% of the population have developed antibodies to the toxin by their late teens or early twenties. Most infants are born with high protective levels of antibody because of the transfer of IgG across the placenta. However, IgG is slowly metabolised, and there is no protection after 3 to 6 months.

A few cases of toxic shock syndrome are caused by staphylococcal enterotoxins that cause food poisoning. Similar symptoms are caused by group A streptococci, organisms recently newsworthy for causing necrotizing fasciitis.(1)

Recognition and differential diagnosis

The symptoms of toxic shock syndrome are non-specific, and the diagnostic criteria rather academic. In practice, if a woman presents to her general practitioner with severe influenza-like symptoms (especially when there is no flu around), awareness of toxic shock syndrome should trigger two questions:

Are you menstruating?
Have you been, or are you, using tampons?

Similar, influenza-like symptoms may be the precursors of several other diseases, some more common, some rare. Every general practitioner is alert for meningitis, while rarer diseases such as Lyme disease, caused by a spirochaete that is spread by the deer tick, occur in various parts of the UK.

In hospital, full-blown toxic shock syndrome may need to be distinguished from severe drug hypersensitivity, Gram-negative shock and streptococcal-like toxic shock syndrome.

Incidence

Toxic shock syndrome is not a notifiable disease in the UK, where one study(2) has quoted the number of cases as 18 per year over the period 1985-1991. However, the authors accept that this could be an underestimate; the real figure is unknown but certainly higher. The figure quoted does not include children with burns, a group in whom the clinical diagnosis can be masked by good antibody protection.

Marples and Wieneke (2) state that 50% of their cases were found in menstruating women who used tampons. However, the syndrome also occurs in men and non-menstruating women who may have infection associated with insect bites, surgical wounds, abscesses or carbuncles, post-operative infection after ear, nose or throat surgery (especially if nasal packing has been used), straphylococcal pneumonia or laryngotracheal bronchitis.

Tampons

Toxic shock syndrome was described in the USA in the late 1970s. In the early 1980s there was an epidemic of the syndrome among menstruating women, mostly in those who were using a highly absorbent type of tampon unavailable in the UK. Why should the syndrome be linked with menstruation? One contributing factor may be an aspect of vaginal physiology. During menses the pH of the vagina rises from its normally acid level, so that Staph. aureus is more likely to be found there. Introduction of oxygen into the vagina as the tampon is inserted could also aid staphylococcal growth.

Advice to patients

Patients may ask the general practitioner for advice about avoiding menstrually associated toxic shock syndrome. Warnings are now printed on all tampon packs and detailed information given on the package insert.

There has been controversial debate among tampon manufacturers that may be entering the public's consciousness. Claims have been made that all-cotton tampons are less likely to be associated with toxic shock syndrome than are those made from the normal cotton/rayon mixture. These claims have not been confirmed and are being specifically refuted. Once absorbency has been taken into account, all types of tampon have an equal but minute risk of being associated with toxic shock syndrome.

The general practitioner may be asked whether it is safe to use tampons after a presumed attack of toxic shock syndrome or whether toxic shock syndrome can be recurrent. Any woman who has suffered from toxic shock syndrome should not use tampons again, although that advice could be changed if plasma antibodies to the toxin could be demonstrated. It is likely that a test to measure the blood levels of toxic shock syndrome anti-bodies will be developed. In a very few cases the syndrome can recur on a monthly basis with minor symptoms; in such cases the diagnosis is entirely clinical.

Treatment

Early diagnosis is the key to successful treatment of toxic shock syndrome. Early treatment prevents triggering of the cytokine cascade that causes multiple complications.

After removal of the tampon or drainage of the infected site, treatment is with antibiotics, intravenous fluids, ionotropics to maintain the blood pressure, intravenous IgG, plus any specific intensive care treatment that may be necessary.

Conclusions

Toxic shock syndrome is a rare and potentially fatal disease of which the public are becoming increasingly aware. Half of the cases are associated with (but not caused by) the use of tampons during menstruation. Women who use tampons can reduce their risk of the disease by sensible precautions. Early diagnosis and treatment is essential, and requires general practitioners to be aware that a flu-like illness in a young woman could be toxic shock syndrome.

Key points

Toxic shock syndrome is a rare disease that can occur in men, women or children. Most cases are caused by a toxin produced by 10 to 20% of the strains of Staphylococus aureus, a bacterium present intermittently in 10 to 30% of the population and found on the skin, fingers, groin and in the vagina.
The disease is rare because most people develop protective antibodies during childhood; 80 to 90% of the population are immune by their early twenties.
Fifty per cent of cases occur in menstruating women who are using tampons. Warnings are now printed on all tampon boxes and detailed information printed on the package inserts.
The signs and symptoms of toxic shock syndrome are rather non-specific and diagnosis requires a high level of suspicion. Early diagnosis and immediate hospital admission for specific treatment is essential.

References

1. Williams GR. The toxic shock syndrome. Br Med J 1990; 300: 960.
2. Marples RR, Wieneke AA. Enterotoxins and toxic shock syndrome toxin 1 in nonenteric staphylococcal disease. Epidemiol Infect 1993; 100: 477-88.