Toxic shock syndrome
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Toxic shock syndrome (TSS) is a rare, acute and serious illness, affecting around 40 people in the UK each year. Anyone can get TSS – men, women and children. Younger people are at greater risk, as older people are more likely to have built up the antibodies needed to protect them from the toxins. However, it is so rare that most doctors will not see a case of TSS during their medical career.
The toxins involved are poisons made by bacteria named Staphylococci or Streptococci. Staphylococcus aureus normally live harmlessly on the skin and in the nose, armpit, groin or vagina of one in every three people.
Shock is a condition caused by the effect of these toxins in some situations, where the blood pressure falls dramatically. A number of clinical problems including fever and rash, as well as shock, must also be present in order for this diagnosis to be made.
Symptoms of TSS may be similar to severe ‘flu, initially. They include:
- a sunburn-like rash
- muscle aches
- a sudden high temperature (fever)
- drowsiness or confusion
- fainting and/or dizziness, and
Patients look pale, and have a high pulse rate. Children with shock will often show confusion as an early sign.
Toxic shock syndrome caused by Streptococci is more common than that caused by Staphylococci. TSS develops when Streptococci spread from damaged tissue into the bloodstream. This can happen following accidents, surgery, insect bites (rarely), chickenpox, or some infections. It can be difficult to treat as it is often accompanied by dying tissue (called necrotising fasciitis).
Staphylococcal TSS does not require bacteria to get into the blood: they make their toxins at the body surface. Staphylococcal TSS can develop following minor burns, boils, surgery, ‘flu and in some cases menstruation (most commonly when a tampon has been used). Tampon-associated TSS rates are low – there are around 4-5 identified cases a year. Staphylococcal TSS has a lower death rate and is often more straightforward to treat.
It still isn’t clear why certain bacteria make the toxins in some situations and not others. It’s also unclear why many people don’t become ill after being exposed to such toxins. Children and young people are more likely to get TSS because the antibodies needed to protect against TSS may take several years to develop.
The number of TSS deaths have gone down over the last 20 years because people are becoming more aware of the risks: it is very important to detect shock early, and get emergency treatment as quickly as possible.
For doctors to reach a diagnosis of Toxic Shock Syndrome, there must be:
- shock (low blood pressure),
- a high fever,
- a sunburn-like rash,
- problems with the gut such as vomiting or diarrhoea
- damage to other organs such as muscles (with pain), the liver (with jaundice) or the kidneys (with changes in the urine).
However, there is no specific blood test for toxic shock syndrome. For this reason the diagnosis of toxic shock syndrome must represent a collection of problems that might have different causes.
The organs requiring the most blood – the brain, the lungs and the kidneys – will be damaged if shock is not treated rapidly. Shock is accompanied by changes in the signalling systems of immune cells and the blood clotting system; ideal treatment involves tackling these disorders too.
Long term studies of TSS suggest that if patients survive the initial illness – the shock in particular – there should be very few long-term physical effects. Women who have contracted TSS as an association of using tampons often find that their fertility has been unaffected. However it is also known that TSS may recur, perhaps because those who develop TSS have difficulties protecting themselves against the toxins.
First of all, it is important to give oxygen to any shocked patient. The blood volume needs to be increased.
Patients should receive fluids directly into the bloodstream (intravenous) for this. In hospital other measures may be used to improve blood pressure and heart function.
The source of toxins - the bacteria - needs to be removed using antibiotics. The antibiotic clindamycin is preferred over others as it stops bacteria making proteins including these toxin molecules.
The toxins themselves can be neutralised using intravenous immunoglobulins. These are antibodies from blood donors, some of which are likely to stop the activity of the toxin molecules.
If the patient is using a tampon, it should be removed immediately at the first sign of a fever or rash. If TSS is diagnosed, this action may help to prevent symptoms from worsening.
The toxins made by Streptococci and Staphylococci are powerful. They are being used to make vaccines against Staphylococci and Streptococci themselves, which might be of considerable value to many patients in the future.
The link between TSS and tampon use is unclear. Research suggests that for cases which occur in women using tampons, tampon absorbency is a factor. For this reason it is important that women:
- always use a tampon with the lowest absorbency suitable for period flow
- use a sanitary towel or panty liner from time to time during their period
- wash their 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 at night, insert a fresh tampon before going to bed and remove it on waking
- remove a tampon at the end of a period.
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