Many people have heard of Toxic Shock Syndrome (TSS) and know that the infection is often associated with using tampons. However, not as many know that other risk factors associated with contracting TSS include using sanitary pads and menstrual cups, and that others don't involve having a period at all – men and children can also contract the rare condition.
We asked Dr Deborah Lee, of Dr Fox Online Pharmacy, to explain exactly what Toxic Shock Syndrome is, what the symptoms are and how it can be treated (yep, fear not - if caught early, most people make a full recovery). Given that some symptoms are similar to heat exhaustion (or sun stroke), it's advised that you're extra vigilant with checking-in with yourself during the summer months too.
What is Toxic Shock Syndrome?
"TSS is the medical term for a set of characteristic symptoms that appear when a bacterial infection occurs in the body, the bacteria in question being Group A streptococcus (sometimes referred to as GAS) and staphylococcus aureus," says Dr Lee, explaining that these same types of bacteria can produce dangerous toxins. "Many people carry these infections on their skin or in their throat all the time but don't become ill. It’s not clear why others can go on to develop rare, life-threatening infections from these same bacteria."
What is the cause of Toxic Shock Syndrome?
Whilst Dr Lee has already explained that it's certain strains of bacteria (which many people have in their bodies all the time but never develop an infection from) that cause TSS, there are also other factors which are viewed as associated risks. "However, 20-50% of cases occur in people with no predisposing risk factors at all," says Dr Lee.
These risk factors include:
- Wounds, such as burns.
- Infections after childbirth, miscarriage and abortion.
- After surgery.
- Respiratory infections.
- Intravenous drug use.
- HIV infection.
- After the flu.
- Intrauterine Device (IUD) insertion.
- Tampon use, contraceptive caps or diaphragms and sponges.
What are the first signs of Toxic Shock Syndrome?
Typical signs to keep an eye out for include: a high fever (over 39ºC), flu-like symptoms and chills. Nausea and vomiting, diarrhoea, a headache, muscle pains and sometimes a sore throat and difficulty swallowing, too. "The patient's blood pressure can drop low, leading to weakness, confusion and lowered levels of consciousness and there may also be a skin rash," says Dr Lee. It depends on where the infection has originated from, but pain is often another common feature. "The bacteria may have arisen from any number of sites in the body, for example from a pelvic infection, ear infection or a surgical wound."
How are the symptoms of Toxic Shock Syndrome similar to sunstroke or heat exhaustion?
"Humans have an in-built mechanism to keep the body temperature between 36.5 to 37.5 C. In hot weather, our bodies are silently working hard to cool us down," explains Dr Lee, adding that in a heatwave, for instance, if you're vulnerable, or unable to keep cool, heat exhaustion may follow. "Heat exhaustion differs to sunburn – it occurs when your body overheats, and the symptoms are caused by the effects of your body over-heating – and symptoms can mimic other conditions, such as Toxic Shock Syndrome (TSS)."
She adds that both conditions are linked to having a high temperature, stomach pains, nausea and vomiting. "In heat exhaustion, the body temperature is below 40 C, whereas with TSS it is elevated, but slightly lower at under 39 C." In heat exhaustion, the symptoms are due to over-heating, and dehydration. As the body tries to cool down, sufferers could experience sweating, a rapid heart rate, fast breathing and painful cramps. "In TSS, the symptoms are largely due to the overwhelming infection and toxin production. This gives rise to exhaustion, fatigue, a skin rash, and other symptoms such as a sore throat, a cough, and sometimes difficulty breathing."
There also rashes to consider: with TSS, it may cover the whole body (or just the groin and armpits) and typically the tongue appears red and furry. A rash associated with a heat-based condition usually has tiny fluid-filled blisters or sometimes small, flat, red spots. "These are caused by blocked sweat glands," notes Dr Lee.
How can you tell what could be causing your symptoms? "The clue to the diagnosis is in the history. What has happened in the run-up to these symptoms developing? If you have been in a hot environment and become over-heated, heat exhaustion is more likely," says Dr Lee. "If however, these symptoms have come out of the blue, even if you have been out in the sun but you took the correct measures to keep cool, and specifically if you have a tampon or other device in the vagina or have only recently removed one, this points to TSS." If you think you have heat exhaustion, move to a cool place, take a cold drinks, elevate your feet and legs, spray your skin with cooling water and rest. If you're not feeling better after 30 minutes, you should phone 999 or get to A&E.
How soon do symptoms of Toxic Shock Syndrome appear?
Signs of TSS can develop within 12 hours of having a surgical procedure. If TSS is associated with menstruation and the use of tampons, symptoms usually come on within 3 to 5 days of the beginning of the period. "Up to half of all cases have no obvious cause, however, TSS is seen as a medical emergency, so you should seek help immediately – either by calling 999 or going to the Emergency Department – if you're showing any symptoms," urges Dr Lee. Urine and blood tests will help to confirm the diagnosis.
What is Toxic Shock Syndrome rash?
"The rash associated with TSS can appear as either general reddening of the skin, sometimes macular (flat red patches, usually less than 1cm), or as a fine, red, bumpy rash, a bit like sandpaper," Dr Lee explains. The palms of the hands and soles of the feet, the inside of the mouth, the whites of the eyes and the tongue may all look bright red too. "After about 2 weeks, the rash usually peels off by itself and the skin is shed."
How long do you have to wear a tampon to get Toxic Shock Syndrome?
"It’s important to be clear – tampons don't cause TSS, but they are co-factors in the development of the condition," says Dr Lee. "TSS can also occur in children, in men and in women when they're not menstruating." On the topic of tampons though, she advises following the manufacturer's instructions to the letter and not leaving one in for over 8 hours.
"Always insert a new tampon before going to sleep and set your alarm to prevent oversleeping the next morning. If your flow is light, use a pad instead, and if you feel unwell at any point while using a tampon, remove it immediately and seek help." It's also worth noting that tampons have an expiry date, so be sure to check the box for one before using too.
Do tampons cause Toxic Shock Syndrome?
As we've already heard, no – but some elements associated with tampons can increase the risk. "Inserting the tampon allows more oxygen into the vagina which can lead to an increase in bacteria," says Dr Lee. "Tears in the vaginal wall can facilitate the entry of infection into the body too. Very small rips can even occur when sliding a tampon into a dry vagina." Washing your hands before inserting or removing a tampon, a cap, diaphragm or contraceptive sponge will help to lower the risk of infection. Ditto keeping an eye on how long they've been in there for.
Can you get Toxic Shock Syndrome from wearing a pad?
"Yes, however, this doesn't mean that the sanitary towel has caused the infection," stresses Dr Lee. "The bacteria is always what causes the infection. However, in cases of TSS which occur in menstruating women, the risk, although very small, is higher in women using tampons than pads." It's also possible to contract TSS while using a menstrual cup.
Can Toxic Shock Syndrome cause death?
Sadly, if not treated in time, it can. "The infection progresses very rapidly and within hours can be overwhelming," says Dr Lee. "It can cause your vital organs to stop working properly, leading to kidney failure, respiratory failure, heart failure and death." She notes that a common death rate statistic for TSS is that 5 to 15% of cases are fatal, however, in one study conducted in 2002, there was a death rate of 64%. Just remember though, the infection is incredibly rare.
How is Toxic Shock Syndrome treated?
Treatment for TSS might include antibiotics, oxygen to help with difficulties breathing, blood pressure medicine and in extreme cases, surgery to remove any dead tissue. In very rare instances, amputation may be necessary.
For more information on Toxic Shock Syndrome, visit the NHS website.
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