Toxic Shock Syndrome



Toxic shock syndrome (TSS) is an acute febrile illness characterized by hypotension and gastrointestinal and respiratory distress progressing to multisystem organ failure. The clinical syndrome is caused by bacterial exotoxins produced most commonly by the following:

  • TSS toxin-1 (TSST-1)–producing strains of Staphylococcus aureus—referred to as TSS in this section
  • Group A β-hemolytic streptococci (GAS or Streptococcus pyogenes), referred to as streptococcal toxic shock–like syndrome (STSS) in this section
  • Cases have also been reported in association with groups B, C, and G1 streptococci and Streptococcus mitis.


  • In the 1980s, most cases were associated with superabsorbent tampon use.
    • Subsequent decline in menstrual-related staphylococcal TSS after removal of these products from the market
    • Currently, ~50% of cases are non–menstrual related.
  • Higher burden for STSS in developing countries


  • TSS: 3.4 cases per 100,000 in 2003
  • Current incidence of menses-related TSS: 1 to 5 per 100,000 women of menstrual age per year
  • STSS: 2 to 4 cases per 100,000 in developed countries with >10 per 100,000 per year in developing countries
  • STSS incidence is highest among young children and associated with focal infections, pneumonia, or bacteremia.

Risk Factors

  • Use of superabsorbent tampon, diaphragm, or contraceptive sponge; local or invasive staphylococcal or streptococcal infection
  • Recent gynecologic procedure
  • Focal infections including surgical and postpartum wounds, sinus, soft tissue, and musculoskeletal infections and respiratory infections
  • STSS most often occurs with skin and soft tissue infections.
    • Preceding varicella infection increases risk.

General Prevention

  • Scrupulous wound care
  • Limitation of intravaginal foreign body use (e.g., tampon, sponge) and strict adherence to manufacturer’s directions
  • Early recognition and appropriate treatment of infections


  • Both S. aureus and S. pyogenes can produce exotoxins.
  • Some exotoxins function as superantigens, interacting with immune cells to induce massive cytokine production leading to the predominant symptoms.
  • Cytokines result in fever, capillary leak, hypotension, and end-organ dysfunction.

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