Toxic Shock Syndrome

Definition:-
Toxic shock syndrome (TSS) is a very rare but potentially fatal illness caused by a bacterial toxin. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative bacteria include Staphylococcus aureus and Streptococcus pyogenes. Streptococcal TSS is sometimes referred to as toxic shock-like syndrome (TSLS) or Streptococcal Toxic Shock Syndrome (STSS).

TSS, is a serious condition which mainly affects menstruating women using tampons. The patient develops a high fever, diarrhea, vomiting and muscle ache. This is followed by hypotension (low blood pressure), which may eventually lead to shock and death. In some cases there may be a sunburn-like rash with skin peeling.

Experts are not sure why such a significant proportion of toxic shock syndrome patients are women who are menstruating and using a tampon – especially “super absorbent” tampons.

Toxic shock syndrome may also occur as a result of an injury, burn or as a complication of localized infections, such as a boil, as well as with the use of contraceptive sponges.

According to the National Health Service (NHS), UK, approximately 20 patients develop toxic shock syndrome each year in the United Kingdom, of which about 3 die. According to the Centers for Disease Control and Prevention (CDC), USA, toxic shock syndrome affects approximately 1 to 2 in every 100,000 women aged 15-44 years in the USA every year.

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Main Routes of infection:-
TSS can occur via the skin (e.g., cuts, surgery, burns), vagina (prolonged tampon exposure), or pharynx. However, most of the large number of individuals who are exposed to or colonized with toxin-producing strains of S. aureus or S. pyogenes do not develop toxic shock syndrome. One reason is that a large percentage of the population have protective antibodies against the toxins that cause TSS. It is not clear why the antibodies are present in people who have never had the disease, but likely that given these bacteria’s pervasiveness and presence in normal flora, minor cuts and such allow natural immunization on a large scale.

It is believed that approximately half the cases of staphylococcal TSS reported today are associated with tampon use during menstruation. However, TSS can also occur in children, men, and non-menstruating women.

Although scientists have recognized an association between TSS and tampon use, no firm causal link has been established. Research conducted by the CDC suggested that use of some high-absorbency tampons increased the risk of TSS in menstruating women. A few specific tampon designs and high-absorbency tampon materials were found to have some association with increased risk of TSS. These products and materials are no longer used in tampons sold in the U.S. (The materials include polyester, carboxymethylcellulose and polyacrylate). Tampons made with rayon do not appear to have a higher risk of TSS than cotton tampons of similar absorbency.

Toxin production by S. aureus requires a protein-rich environment, which is provided by the flow of menstrual blood, a neutral vaginal pH, which occurs during menstruation, and elevated oxygen levels, which are provided by the tampon that is inserted into the normally anaerobic vaginal environment. Although ulcerations have been reported in women using super-absorbent tampons, the link to menstrual TSS, if any, is unclear. The toxin implicated in menstrual TSS is capable of entering the bloodstream by crossing the vaginal wall in the absence of ulcerations. Women can avoid the risk of contracting TSS by choosing a tampon with the minimum absorbency needed to manage their menstrual flow and using tampons only during active menstruation. Alternately, a woman may choose to use a different kind of menstrual product that may eliminate or reduce the risk of TSS, such as a menstrual cup or sanitary napkin.

History:-
Initial description of toxic shock syndrome
The term toxic shock syndrome was first used in 1978 by a Denver pediatrician, Dr. James K. Todd, to describe the staphylococcal illness in three boys and four girls aged 8–17 years. Even though S. aureus was isolated from mucosal sites in the patients, bacteria could not be isolated from the blood, cerebrospinal fluid, or urine, raising suspicion that a toxin was involved. The authors of the study noted that reports of similar staphylococcal illnesses had appeared occasionally as far back as 1927. But the authors at the time failed to consider the possibility of a connection between toxic shock syndrome and tampon use, as three of the girls who were menstruating when the illness developed were using tampons. Many cases of TSS occurred after tampons were left in the woman using them.

Rely tampons:-
Following a controversial period of test marketing in Rochester, New York and Fort Wayne, Indiana, in August 1978 Procter and Gamble introduced superabsorbent Rely tampons to the United States market in response to women’s demands for tampons that could contain an entire menstrual flow without leaking or replacement. Rely used carboxymethylcellulose (CMC) and compressed beads of polyester for absorption. This tampon design could absorb nearly 20 times its own weight in fluid. Further, the tampon would “blossom” into a cup shape in the vagina in order to hold menstrual fluids without leakage.

Package of Rely Tampons

In January 1980, epidemiologists in Wisconsin and Minnesota reported the appearance of TSS, mostly in menstruating women, to the CDC. S. aureus was successfully cultured from most of the women. A CDC task force investigated the epidemic as the number of reported cases rose throughout the summer of 1980, accompanied by widespread publicity. In September 1980, the CDC reported that users of Rely were at increased risk for developing TSS.

On September 22, 1980, Procter and Gamble recalled Rely following release of the CDC report. As part of the voluntary recall, Procter and Gamble entered into a consent agreement with the FDA “providing for a program for notification to consumers and retrieval of the product from the market.” However, it was clear to other investigators that Rely was not the only culprit. Other regions of the United States saw increases in menstrual TSS before Rely was introduced. It was shown later that higher absorbency of tampons was associated with an increased risk for TSS, regardless of the chemical composition or the brand of the tampon. The sole exception was Rely, for which the risk for TSS was still higher when corrected for its absorbency. The ability of carboxymethylcellulose to filter the S. aureus toxin that causes TSS may account for the increased risk associated with Rely.

By the end of 1980, the number of TSS cases reported to the CDC began to decline. The reduced incidence was attributed not only to the removal of Rely from the market, but also to reduced use of all tampon brands. According to the Boston Women’s Health Book Collective, 942 women were diagnosed with tampon-related TSS in the USA from March 1980 to March 1981, 40 of whom died.

Symptoms:-
Symptoms of toxic shock syndrome vary depending on the underlying cause. TSS resulting from infection with the bacteria Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress to stupor, coma, and multi-organ failure. The characteristic rash, often seen early in the course of illness, resembles a sunburn, and can involve any region of the body, including the lips, mouth, eyes, palms and soles. In patients who survive the initial onslaught of the infection, the rash desquamates, or peels off, after 10–14 days.

Signs and symptoms of TSS (toxic shock syndrome) develop suddenly:
Sudden high fever (first symptom) The following signs and symptoms normally appear within a few hours:

*Vomiting
*Diarrhea
*Sunburn-like skin rash, particularly in the palms and soles
*Redness of eyes, mouth and throat
*Fainting
*Feeling faint
*Muscle aches
*Dizziness
*Confusion
*Hypotension (low blood pressure)
*Seizures
*Headaches

Causes of toxic shock syndrome :-
Scientists have been investigating the causes of TSS for over two decades and are still baffled. 20% to 30% of all humans carry the TSS causing bacterium, Staphylococcus aureus on their skin and nose; usually without any complications. Most of us have antibodies which protect us. Scientists believe that some of us do not develop the necessary antibodies.

Some experts suggest that the super-absorbent tampons – the ones that stay inside the body the longest – become breeding grounds for bacteria, while others believe the tampon fibers may scratch the vagina, making it possible for bacteria to get through and into the bloodstream. However, both are just theories without any compelling evidence to back them up.

We do know that the bacteria get into the body via wounds, localized infections, the vagina, the throat or burns. When the toxins (produced by the bacteria) enter the bloodstream they mess up the blood pressure regulating process, resulting in a hypotension (low blood pressure). Hypotension can cause dizziness and confusion (shock). The toxins also attack tissues, including organs and muscles. Kidney failure is a common TSS complication.

TSS does not only develop in young menstruating women. Older women, men and children may also be affected. Women who have been using a diaphragm or a contraceptive sponge have a slightly higher risk of developing TSS. In fact, anyone with a staph or strep infection has the potential to develop TSS (even though it is extremely rare).

Diagnosis:-
In contrast, TSS caused by the bacteria Streptococcus pyogenes, or TSLS, typically presents in people with pre-existing skin infections with the bacteria. These individuals often experience severe pain at the site of the skin infection, followed by rapid progression of symptoms as described above for TSS. In contrast to TSS caused by Staphylococcus, Streptococcal TSS less often involves a sunburn rash.

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In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections.:

1.Body temperature > 38.9 °C (102.02 °F)
2.Systolic blood pressure < 90 mmHg
3.Diffuse rash, intense erythroderma, blanching (“boiled lobster”) with subsequent desquamation, especially of the palms and soles
4.Involvement of three or more organ systems:

*Gastrointestinal (vomiting, diarrhea)
*Mucous membrane hyperemia (vaginal, oral, conjunctival)
*Renal failure (serum creatinine > 2x normal)
*Hepatic inflammation (AST, ALT > 2x normal)
*Thrombocytopenia (platelet count < 100,000 / mm³)
*CNS involvement (confusion without any focal neurological findings)

To date, there is no specific TSS test. The doctor needs to identify the most common symptoms, as well as checking for signs of organ failure.

*Blood and urine tests – these help determine organ function (or organ failure).

According to the National Health Service (NHS), UK, a confident TSS diagnosis can generally be made when:

*The patient’s temperature is above 38.9C (102.02F)
*The patient’s systolic blood pressure is below 90 mmHG
*The patient has a skin rash
*There is evidence that at least three organs have been affected by the infection

Pathogenesis:-
In both TSS (caused by Staph. aureus) and TSLS (caused by Strep. pyogenes), disease progression stems from a superantigen toxin that allows the non-specific binding of MHC II with T cell receptors, resulting in polyclonal T cell activation. In typical T cell recognition, an antigen is taken up by an antigen-presenting cell, processed, expressed on the cell surface in complex with class II major histocompatibility complex (MHC) in a groove formed by the alpha and beta chains of class II MHC, and recognized by an antigen-specific T cell receptor. By contrast, superantigens do not require processing by antigen-presenting cells but instead interact directly with the invariant region of the class II MHC molecule. In patients with TSS, up to 20% of the body’s T cells can be activated at one time. This polyclonal T-cell population causes a cytokine storm, followed by a multisystem disease. The toxin in S. aureus infections is Toxic Shock Syndrome Toxin-1, or TSST-1.

Treatment:-
The medical team’s aim is to fight the infection as well as supporting any body functions that the infection may have affected. The patient will be hospitalized and may be placed in an intensive care unit.

*Oxygen – the patient will usually be given oxygen to support breathing.

*Fluids – fluids will be administered to prevent dehydration and to bring blood pressure back up to normal.

*Kidneys – a dialysis machine will be used if there is kidney failure. The machine filters toxins and waste out of the bloodstream.

*Other damage – damage to skin, fingers or toes will need to be treated. This often involves draining and cleaning. In severe cases a body extremity or parts of skin may need to be surgically removed.

*Antibiotics – a combination of antibiotics is administered intravenously (directly into the bloodstream).

*Immunoglobulin – these are samples of donated human blood with high levels of antibodies which can fight the toxin. In some cases the medical team may administer immunoglobulin as well as antibiotics.
In the majority of cases the patient responds to treatment within a couple of days. However, he/she may have to stay in hospital for several weeks.

Click to see :->Streptococcal Toxic-Shock Syndrome: Spectrum of Disease, Pathogenesis, and New Concepts in Treatment

Prognosis :-
With proper treatment, patients usually recover in two to three weeks. The condition can, however, be fatal within hours.

Prevention:
Before going through about possible preventive measures, it is important to remember that the risk of developing TSS is very low. A significant number of experts point to a probably link between tampon absorbency and TSS risk, and advise women to:

*Thoroughly wash their hands before inserting a tampon
*Use the lowest absorbency tampons for their period flow
*Switch from tampons to sanitary towels (or panty liners) during their period
*Change tampons at least as regularly as directed on the pack
*Insert only one tampon at a time (never more than one)
*Insert a fresh tampon when going to bed and replace it immediately in the morning
*Remove the tampon as soon as the period has ended

The Mayo Clinic, USA, advises women to avoid using tampons completely when their flow is very light (use minipads instead).

The National Health Service (NHS), UK, advises that people who have had TSS should avoid using tampons.

Women who use a diaphragm, cap or contraceptive sponge should follow the manufacturer’s instructions carefully (regarding how long to leave the device inside the vagina). The NHS advises women who have had TSS to use an alternative method of contraception.

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Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Toxic_shock_syndrome
http://www.medicalnewstoday.com/articles/175736.php

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