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Toxic shock syndrome (TSS) is a very rare but potentially fatal illness caused by a bacterial toxin. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative-positive bacteria include Staphylococcus aureus and Streptococcus pyogenes. Streptococcal TSS is sometimes referred to as Toxic shock-like syndrome (TSLS).
TSS can occur via the skin (e.g., cuts, surgery, burns), vagina, (prolonged tampon exposure), or pharynx. However, most of the large number of individuals who are exposed to, or colonized with toxin-producing strains of S. aureus or S. pyogenes do not develop toxic shock syndrome. One reason is that a large percentage of the population have protective antibodies against the toxins that cause TSS.[1] It is not clear why the antibodies are present in people who have never had the disease, but likely that given these bacterium’s cosmopolitan nature and makeup of normal flora, minor cuts and such allow a natural immunization on a small scale.
The number of reported staphylococcal toxic shock syndrome cases has decreased significantly in recent years. It is believed that approximately half the cases of staphylococcal TSS reported today are associated with tampon use during menstruation. TSS can also occur in children, men, and non-menstruating women. It has been estimated that only 1 to 17 out of every 100,000 menstruating females will get TSS.[2]
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. 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.[4]
Toxin production by S. aureus requires a protein-rich environment, which is provided by the flow of menstrual blood, a neutral vaginal pH, which occurs during menstruation, and elevated oxygen levels, which is provided by the tampon that is inserted into the normally anaerobic vaginal environment.[5] Although ulcerations have been reported in women using super absorbent tampons, the link to menstrual TSS, if any, is unclear. The toxin implicated in menstrual TSS is capable of entering the bloodstream by crossing the vaginal wall in the absence of ulcerations.[6] Women can avoid the risk of contracting TSS by choosing a tampon with the minimum absorbency needed to manage their menstrual flow and using tampons only during active menstruation. Alternately, a woman may choose to use a different kind of menstrual product that may eliminate or reduce the risk of TSS, such as sanitary napkin.
The term toxic shock syndrome was first used in 1978 by a Denver pediatrician, Dr. James K. Todd, to describe the staphylococcal illness in three boys and four girls aged 8-17 years.[7] Even though S. aureus was isolated from mucosal sites from the patients, bacteria could not be isolated from the blood, cerebrospinal fluid, or urine, raising suspicion that a toxin was involved. The authors of the study noted that reports of similar staphylococcal illnesses had appeared occasionally as far back as 1927. Most notably, the authors at the time failed to consider the possibility of a connection between toxic shock syndrome and tampon use, as three of the girls who were menstruating when the illness developed were using tampons. Over 37,000 cases in 2001 were reported to the Department of Health and Human Services that showed cases of TSS after Tampons were either left in or lost inside of the woman. [8]
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