What is the likely diagnosis and treatment for a female of reproductive age with a history of tampon use, presenting with symptoms after a retained tampon?

Toxic Shock Syndrome from Retained Tampon

The syndrome caused by a retained tampon is Toxic Shock Syndrome (TSS), a life-threatening condition requiring immediate recognition, removal of the tampon, aggressive fluid resuscitation, anti-staphylococcal antibiotics, and intensive care monitoring.

Clinical Presentation

TSS presents with acute onset of fever (≥38.9°C), hypotension or syncope, diffuse erythematous maculopapular rash with subsequent desquamation (particularly of palms and soles), and multisystem organ involvement 1, 2. The condition can progress from initial symptoms to hypotensive shock within 24 hours 3, 4.

Cardinal Features to Recognize

• Fever and hypotension: Temperature ≥38.9°C with systolic blood pressure <90 mmHg or orthostatic dizziness/syncope 2, 4
• Characteristic rash: Diffuse macular erythroderma resembling scarlet fever or sunburn, followed by desquamation 1-2 weeks later, especially on palms and soles 1, 2
• Mucous membrane inflammation: Hyperemia of conjunctivae, oropharynx, or vagina 2
• Gastrointestinal symptoms: Vomiting and profuse watery diarrhea 1, 2
• Myalgias and malaise: Severe muscle pain and profound weakness 2, 4

Laboratory Evidence of Multisystem Dysfunction

• Renal: Elevated creatinine, acute kidney injury 1, 2
• Hepatic: Elevated transaminases and bilirubin 2
• Hematologic: Thrombocytopenia (<100,000/mm³), elevated white blood cell count 1, 2
• Metabolic: Elevated lactate indicating tissue hypoperfusion 1

Immediate Diagnostic Steps

Perform a pelvic examination in all young females presenting with unexplained shock—this is mandatory and should never be deferred 1. The examination will reveal:

• Retained tampon (often forgotten or left in place for extended periods) 5
• Purulent vaginal discharge 1
• Vaginal mucosal hyperemia 2

Obtain vaginal/cervical cultures for Staphylococcus aureus and TSS toxin-1 (TSST-1) testing 1, 2. Blood cultures should also be obtained, though bacteremia occurs in only a minority of cases 2.

Treatment Algorithm

Step 1: Source Control (Immediate)

Remove the retained tampon immediately upon discovery 1, 4, 5. This is the single most critical intervention as it eliminates the source of ongoing toxin production 4.

Step 2: Hemodynamic Resuscitation

Administer aggressive fluid resuscitation with both crystalloids and colloids 4. Patients typically require large volumes due to capillary leak syndrome causing fluid shift into interstitial spaces 4:

• Begin with crystalloid boluses (normal saline or lactated Ringer's) 4
• Add colloid solutions (albumin or intravenous immunoglobulin) as needed to maintain adequate venous return and cardiac output 4
• Prepare for vasopressor support if hypotension persists despite fluid resuscitation 1

Step 3: Antimicrobial Therapy

Initiate anti-staphylococcal antibiotics immediately after cultures are obtained 1, 3, 4:

• Preferred regimen: Intravenous oxacillin or nafcillin for methicillin-sensitive S. aureus 3
• If MRSA suspected or confirmed: Vancomycin 4
• Add clindamycin to inhibit bacterial toxin production regardless of susceptibility testing 4

The rationale for clindamycin is critical: it suppresses toxin synthesis even as bacteria are being killed, reducing ongoing toxin-mediated damage 4.

Step 4: Intensive Care Management

Transfer to pediatric or adult intensive care unit for close monitoring and management of complications 1, 4:

• Continuous hemodynamic monitoring 1
• Management of acute respiratory distress syndrome (ARDS) if it develops 4
• Support for myocardial dysfunction 4
• Renal replacement therapy if acute kidney injury progresses 4

Expected Clinical Course

The erythematous rash typically disappears within 24-48 hours of initiating treatment 3. Desquamation of hands and feet begins 1-2 weeks after illness onset and confirms the diagnosis retrospectively 3, 2.

Prognosis and Follow-Up

With early recognition and appropriate therapy, survival exceeds 95% 4. However, mortality remains approximately 8% overall, with deaths occurring primarily when diagnosis is delayed or treatment inadequate 3, 4.

Critical Discharge Instructions

Instruct patients to avoid tampon use for at least 4 months following TSS 3. Recurrence risk is significant if tampons are resumed prematurely, as the patient may remain colonized with toxigenic S. aureus strains 4.

Counsel on alternative menstrual products (pads rather than tampons) and proper hygiene practices 3, 4.

Common Pitfalls to Avoid

Never dismiss shock in a young, previously healthy menstruating female as simple dehydration or viral illness 1. TSS should be in the differential diagnosis of any menstruating woman presenting with fever and hypotension 1.

Do not delay pelvic examination based on patient embarrassment or discomfort—this examination is potentially life-saving 1.

Recognize that milder forms exist 3. Not all patients present with fulminant shock; some may have less severe manifestations but still require treatment to prevent progression 3.

TSS can occur in males and non-menstruating females with soft tissue infections or surgical wounds colonized by toxigenic S. aureus, though this is less common 2.