From the Guidelines
Toxic shock syndrome (TSS) is primarily caused by toxins produced by certain bacteria, most commonly Staphylococcus aureus and sometimes Streptococcus pyogenes, as evidenced by the case definitions for infectious conditions under public health surveillance 1. These bacteria release toxins that enter the bloodstream and trigger a severe immune response. TSS often occurs when these bacteria grow in environments that allow them to produce large amounts of toxins, such as in tampon use, wound infections, surgical sites, or skin infections. Some key points to consider include:
- Risk factors for TSS include menstruation, use of barrier contraceptives like diaphragms or sponges, recent surgery, cuts or burns on the skin, and nasal packing.
- The toxins act as superantigens, causing massive activation of T-cells and release of inflammatory chemicals, leading to the characteristic symptoms of high fever, low blood pressure, rash, and multi-organ dysfunction.
- Prevention includes proper wound care, frequent changing of tampons or other menstrual products, and avoiding leaving foreign objects in the body for extended periods. According to the surviving sepsis campaign guidelines, clindamycin and antitoxin therapies may be used for toxic shock syndromes with refractory hypotension 1. Key aspects of TSS management and prevention should focus on reducing toxin production and mitigating the immune response, with consideration of the most recent and highest quality evidence available.
From the Research
Causes of Toxic Shock Syndrome
Toxic shock syndrome (TSS) is a rare, life-threatening condition caused by toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes 2, 3, 4, 5, 6. The main causes of TSS can be summarized as follows:
- Bacterial superantigenic exotoxins, such as toxic shock syndrome toxin-1 (TSST-1) and enterotoxins for Staphylococcus aureus, and Streptococcal pyrogenic exotoxins (SpE) A, B, and C and streptococcal superantigen A (SsA) for Streptococcus pyogenes 2
- Staphylococcal TSS can be menstrual or nonmenstrual, while Streptococcal TSS is linked to a severe group A streptococcal infection and, most frequently, to a necrotizing soft tissue infection 2
- The syndrome can occur with any site of S. aureus infection, and clinicians of all medical specialties should be aware of the presentation and management 4
Pathophysiology of Toxic Shock Syndrome
The pathophysiology of TSS involves the production of superantigens by the bacteria, which bypass normal antigen presentation and cause a clonal T-cell expansion and uncontrolled release of pro-inflammatory mediators, resulting in severe multiple organ failure 2, 5. This process can be described as follows:
- Bacterial superantigens induce unconventional polyclonal lymphocyte activation, leading to rapid shock, multiple organ failure syndrome, and death 2
- The release of pro-inflammatory mediators results in severe multiple organ failure, which can be fatal if left untreated 5
Types of Toxic Shock Syndrome
There are two main types of TSS: