Toxic shock syndrome

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**Toxic shock syndrome**
*Classifications and external resources*
ICD-10	A 48.3
ICD-9	040.82

Toxic shock syndrome (TSS) is a rare but potentially fatal disease caused by a bacterial toxin. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative agent is Staphylococcus aureus. A similar condition, called Toxic Shock Like Syndrome (TSLS), is the result of Streptococcus pyogenes infection. TSLS is also referred to as Streptococcal TSS.

1 Routes of infection
- 1.1 Rely tampons
2 Symptoms and diagnosis
3 Therapy
4 See also
5 References
6 External links

[edit] Routes of infection

Infection can occur via the skin (e.g. cuts, surgery, burns), vagina (via tampon), or pharynx.

The number of reported toxic shock syndrome cases has decreased significantly in recent years. Approximately half the cases of TSS reported today are associated with tampon use during menstruation, usually in young women, though TSS also occurs in children, men, and non-menstruating women. In the US in 1997, only five confirmed menstrual-related TSS cases were reported, compared with 814 cases in 1980, according to data from the Centers for Disease Control and Prevention (CDC). ^[1]

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 also found to have some association with increased risk of TSS. It has been estimated that each year 1 to 17 of every 100,000 menstruating females will get TSS. ^[2] These products and materials are no longer used in tampons sold in the U.S. (The materials include polyester, carboxymethylcellulose and polyacrylate).^[3] Tampons made with rayon do not appear to have a higher risk of TSS than cotton tampons of similar absorbency.

Vaginal dryness and ulcerations may occur when women use tampons more absorbent than needed for the amount of their menstrual flow. Ulcerations have also been reported in women using tampons between menstrual periods to try to control excessive vaginal discharge or abnormal bleeding. Women may avoid problems by choosing a tampon with the minimum absorbency needed to control menstrual flow and using tampons only during active menstruation. Alternately, women may use a silicone or latex rubber menstrual cup to avoid the negative side-effects of tampons.

[edit] Rely tampons

In the late 1970s, Procter and Gamble introduced superabsorbent Rely tampons^[4] , in response to women's demands for tampons which could contain an entire menstrual flow without leaking or replacement.^[3] Rely used carboxymethylcellulose (CMC) and compressed beads of polyester for absorption. This tampon design could absorb nearly 20 times its own weight in fluid^[5] . Further, the tampon would "blossom" into a cup shape in the vagina in order to hold menstrual fluids.

The superabsorbent properties of Rely caused vaginal dryness by absorbing the natural humidity of the vagina. Often this led to ulcerations in the vaginal wall when the tampon was removed, offering pathways for bacteria to infect the bloodstream^[5] . Further, the tampons' superabsorbency meant that the viscosity of vaginal fluids was enhanced, providing a good environment for bacteria growth^[6] . In addition, CMC has features which effectively filter the toxins of Staphylococcus which cause TSS^[5] . The recipe for disaster came about as a combination of S. aureus naturally benignly occurring in about 5–15% of women^[7] , the insertion of the tampon adding oxygen to the normally anaerobic vaginal environment allowing for increased bacterial growth, and the tampon's super absorbency meant that women did not need to replace them as frequently and so left them in place longer.

According to the Boston Women's Health Book Collective, 942 women were diagnosed with tampon-related TSS in the USA from the March 1980 to March 1981, 40 of whom died.^[6] In September 1980, Procter and Gamble recalled Rely^{[citation needed]} after the Centers for Disease Control and Prevention released a report in mid 1980 explaining the bacterial mechanism which lead to TSS, and that Rely tampons was associated with TSS more than any other tampon. 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".^[8]

[edit] Symptoms and diagnosis

Symptoms of toxic shock syndrome vary depending on the underlying cause. In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections.[1] TSS resultant of 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.

In contrast, TSLS is caused by the bacteria Streptococcus pyogenes, and it 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.

Diagnosis of TSS and TSLS are strictly based on CDC criteria; in general, the presence of high fevers, low blood pressure, confusion, and laboratory evidence of organ failure in the appropriate historical setting (e.g. menstruating woman using tampon, or young individual with pre-existing skin infection), are necessary to make the diagnosis.

[edit] Therapy

Women wearing a tampon at the onset of symptoms should remove it immediately. The severity of this disease results in hospitalisation for treatment. Antibiotic treatment consists of penicillin and clindamycin.

One of the symptoms of toxic shock syndrome is extreme infection of the skin and deeper parts is called fasciitis necroticans (a.k.a. necrotizing fasciitis). It should be attacked surgically without delay.

With proper treatment, patients usually recover in two to three weeks. The condition, however, can be fatal within hours. Some patients are admitted to the intensive care unit for supportive care in case of multiple organ failure.

[edit] See also

[edit] References

^ Center for Devices and Radiological Health, U.S. Food and Drug Administration, Consumer information (Jul 23, 1999) Tampons and Asbestos, Dioxin, & Toxic Shock Syndrome PDF
^ Stayfree - FAQ About Toxic Shock Syndrome (TSS) (2006). Retrieved on 2006-10-13.
^ ^a ^b Citrinbaum, Joanna (Oct. 14, 2003). The question's absorbing: 'Are tampons little white lies?'. The Digital Collegian. Retrieved on 2006-03-20.
^ Finley, Harry. Rely Tampon: It Even Absorbed the Worry!. Museum of Menstruation. Retrieved on 2006-03-20.
^ ^a ^b ^c Vitale, Sidra (1997). Toxic Shock Syndrome. Web by Women, for Women. Retrieved on 2006-03-20.
^ ^a ^b Chapter 13, Toxic Shock Syndrome. Our Bodies, Ourselves. Boston Women's Health Book Collective, Inc. (2005). Retrieved on 2006-03-20.
^ Frederick, Jenn (2001). The Heath and Environmental Dangers of Traditional Menstural Products. The First Taboo: How Menstrual Taboos Reflect and Sustain Women's Internalized Oppression. Retrieved on 2006-03-20.
^ Kohen, Jamie (2001). The History and Regulation of Menstrual Tampons. RTF document. Retrieved on 2006-03-30.

(October 2004) Mandell GL, Owen, Cheatham R, Bennett JE, Bethesda and Dolin R Principles and Practice of Infectious Diseases, 6th, Churchill Livingstone. ISBN 0-443-06673-6. Retrieved during 2005.