From the Research
Toxic shock syndrome is caused by toxins produced by certain bacteria, primarily Staphylococcus aureus and sometimes Streptococcus pyogenes (group A strep). These bacteria release toxins that enter the bloodstream and trigger a severe immune response throughout the body 1. The condition most commonly occurs when these bacteria grow in environments that allow them to multiply rapidly and produce large amounts of toxins, such as in retained tampons, surgical wounds, burns, or skin infections. The bacterial toxins act as superantigens, causing massive activation of T-cells and resulting in the release of inflammatory cytokines that lead to the characteristic symptoms of high fever, low blood pressure, rash, and multi-organ dysfunction.
Key Points
- Risk factors include tampon use (particularly high-absorbency types), use of menstrual cups, contraceptive sponges or diaphragms, recent surgery, skin wounds, and burns 2.
- While anyone can develop toxic shock syndrome, it historically has been associated with menstruating women using tampons 3.
- The management of toxic shock syndrome is a medical emergency and relies on early detection, immediate resuscitation, source control and eradication of toxin production, bactericidal antibiotic treatment, and protein synthesis inhibiting antibiotic administration 1.
- The interest of polyclonal intravenous immunoglobulin G administration as an adjunctive treatment for TSS requires further evaluation 1.
Pathophysiology
The pathophysiology of toxic shock syndrome involves the production of superantigenic exotoxins by Staphylococcus aureus or Streptococcus pyogenes, which induces unconventional polyclonal lymphocyte activation, leading to rapid shock, multiple organ failure syndrome, and death 1. The main described superantigenic exotoxins are 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 1.
Treatment
The treatment of toxic shock syndrome involves a combination of beta-lactam antibiotics, clindamycin, and intravenous immunoglobulin, as well as early intensive care unit (ICU) and surgical team involvement (in selected cases) 4. Clindamycin is superior to penicillin in the treatment of this condition and significantly decreases the mortality rate in TSS 4.