Sudden development of rash in palms and soles accompanied by fever, changes in mental status with renal or respiratory failure indicates onset of TSS. In addition, affected individuals would also exhibit signs of diarrhea, nausea, headache, low blood pressure, seizures, muscle aches, vomiting and development of redness in the eyes, throat and mouth.

The rash that develops often appears like sun burns followed by skin peeling and occurs after a period of 1 to 2 weeks. The common sites of rash development are the palms and area beneath the feet.

Signs and symptoms of TSS often develop suddenly indicating quick and prompt medical intervention. Failure to initiate immediate treatment can cause debilitating complications to set in [7].

• Fever

  Tss characterised by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. [icd9data.com]

  On day 3, she exhibited a fever, generalized rash and multiple organ failure. She was diagnosed with toxic shock syndrome after burns. [ncbi.nlm.nih.gov]

  The most common causes of a fever and a rash in children are viruses and scarlet fever, which affect children younger than 10 years of age. [emedicinehealth.com]

• High Fever

  Tss characterised by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. [icd9data.com]

  Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. [medical-dictionary.thefreedictionary.com]

  Warning signs of TSS include: sudden high fever (usually 102ºF or more) accompanied by vomiting and/or diarrhea, fainting or near-fainting when standing up and dizziness or a sunburn-like rash. [web.archive.org]

  This report describes a previously healthy young man with streptococcal toxic shock syndrome who presented with fatigue, high fever, and suspected extensive streptococcal tonsillopharyngitis. [ncbi.nlm.nih.gov]

  It's Not Just Caused By Tampons Toxic shock occurs when toxins (produced by certain strains of Staphylococcus bacteria) invade the body, leading to a sudden high fever, rash, and other life-threatening complications. [womenshealthmag.com]

• Malaise

  He became sick two days earlier with malaise, chills and shivering. On admission he was hypotensive, anuric, with erythematous rash on his face, neck and chest, with acute renal failure and elevated creatine phosphokinase level. [ncbi.nlm.nih.gov]

  These mild symptoms may include low-grade fever, muscle aches, chills, and malaise (a feeling of general discomfort, uneasiness, or ill health). [emedicinehealth.com]

  CDC criteria for Staphylococcus TSS include: Fever of 102 degrees F or higher Chills Malaise (uneasiness and despair) Headache Fatigue Red, flat rash that covers most of the areas of the body Shedding of the skin in large sheets, especially over the palms [stanfordchildrens.org]

• Vomiting

  Laboratory findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting [icd9data.com]

  Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. [medical-dictionary.thefreedictionary.com]

  This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. [ncbi.nlm.nih.gov]

  If you experience sudden fever, vomiting, diarrhea, dizziness or muscle aches, immediately discontinue tampon use and consult with your doctor. [michigan.gov]

• Diarrhea

  and myalgia, followed by hypotension and in severe cases, shock; a sunburn-like rash with peeling of the skin, especially of the palms and soles, occurs during the acute phase Syndrome characterized by high fever, vomiting, diarrhea, confusion, and [icd9data.com]

  Thousands went to emergency rooms with high fever, vomiting, peeling skin, low blood pressure, diarrhea, and a rash resembling sunburn. [medical-dictionary.thefreedictionary.com]

  This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. [ncbi.nlm.nih.gov]

  If you experience sudden fever, vomiting, diarrhea, dizziness or muscle aches, immediately discontinue tampon use and consult with your doctor. [michigan.gov]

• Nausea

  This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. [ncbi.nlm.nih.gov]

  […] vomiting confusion sleepiness Signs of kidney failure may include: fatigue weakness nausea and vomiting muscle cramps hiccups persistent itching chest pain shortness of breath high blood pressure sleep problems swelling in the feet and ankles problems [healthline.com]

• Abdominal Pain

  A 32-year-old primigravida at 21 weeks of gestation was taken to our hospital with acute severe abdominal pain following fever. On admission the fetus was found to be dead, and intrauterine fetal demise due to placental abruption was suspected. [ncbi.nlm.nih.gov]

  For example, pain in the muscles, abdominal pain (such as after childbirth) or cough" When to seek medical advice If you develop a sudden fever and one or more of the other symptoms, the NHS says it is still extremely unlikely that you have TSS. [mirror.co.uk]

• Strawberry Tongue

  Redness of the eyes, the lips, and the tongue [strawberry tongue] may also occur. The rash also can occur on the palms and soles of the feet .) [emedicinehealth.com]

  This can be associated with hyperemia of the pharynx and conjunctiva, possibly with a “strawberry tongue” appearance (below). [emcrit.org]

  About 25% of patients will have a strawberry tongue. In menstruating patients, the cervicovaginal mucous membranes will also be intensely red. [scielo.br]

• Hypotension

  Toxic shock syndrome (TSS) is an acute toxin-mediated infectious syndrome characterized by fever, hypotension, desquamation, and multiorgan involvement. [ncbi.nlm.nih.gov]

  Tss characterised by high fever, hypotension, rash, multi-organ dysfunction, and cutaneous desquamation during the early convalescent period. The toxins affect the host immune system, causing an exuberant and pathological host inflammatory response. [icd9data.com]

  […] s) 10-ID-14 Clinical Criteria An illness with the following clinical manifestations: Fever: temperature greater than or equal to 102.0°F (greater than or equal to 38.9°C) Rash: diffuse macular erythroderma Desquamation: 1-2 weeks after onset of rash Hypotension [wwwn.cdc.gov]

  Manifestations include high fever, hypotension, diffuse erythematous rash, and multiple organ dysfunction, which may rapidly progress to severe and intractable shock. Diagnosis is made clinically and by isolating the organism. [msdmanuals.com]

  She is persistently hypotensive (BP 85/35 mmHg) despite 2L of crystalloid fluid resuscitation. [lifeinthefastlane.com]

• Tachycardia

  He initially suffered minor trauma playing basketball, and later presented to his pediatrician with fever, vomiting, severe leg pain, tachypnea, and tachycardia. Initially he was misdiagnosed as having gastroenteritis. [emcrit.org]

  The physical findings for staph TSS are fever, tachycardia, hypotension, sun burn type rash (90%), and altered mental status. [clinicaladvisor.com]

  Tachycardia, markedly elevated temperatures, and hypotension which is initially orthostatic are present. [scielo.br]

  Test characteristics of an automated age- and temperature-adjusted tachycardia alert in pediatric septic shock. Pediatr Emerg Care. 2012 Sep. 28(9):889-94. [Medline]. Dauwalder O, Venet F, Javouhey E, Badiou C, Gillet Y, Guignant C, et al. [emedicine.com]

  Altered sensorium with disorientation, somnolence, or agitation is common. 28 In some patients, however, onset is gradual, and the characteristic rash is not seen for several days. 2 Examination usually reveals a patient with fever, tachycardia, low or [glowm.com]

• Refractory Shock

  Despite conventional treatment, the patient developed refractory shock, which was immediately improved with PMX-DHP. [ncbi.nlm.nih.gov]

• Conjunctival Injection

  Over the course of the next 24 to 48 h, generalized edema of face, hands and feet, arthralgias, particularly of the wrists, knees, ankles, fingers, and toes, the erythroderma, conjunctival injection, cough, dizziness and syncope, incontinence, and oliguria [scielo.br]

• Myalgia

  […] findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting, diarrhea, and myalgia [icd9data.com]

  […] equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years Multisystem involvement (three or more of the following organ systems): Gastrointestinal: vomiting or diarrhea at onset of illness Muscular: severe myalgia [wwwn.cdc.gov]

  An influenzalike syndrome, consisting of fever, chills, myalgia, nausea, vomiting, and diarrhea, may be noted in 20% of patients. [emedicine.com]

• Leg Pain

  Several hours after admission, leg pain and purpura-like skin color appeared. [ncbi.nlm.nih.gov]

  Image credits: https://drhem.wordpress.com/2012/04/ [erythroderma image] http://www.freeimages.com/photo/pain-1366480 [leg pain image] About Latest Posts Josh Farkas Josh is the creator of PulmCrit.org. [emcrit.org]

• Skin Rash

  A misconception is that TSS presents with a skin rash and only occurs in women and children; however, it can occur in males and can present without skin changes. [ncbi.nlm.nih.gov]

  They may include Red skin rash that looks like sunburn Red eyes (conjunctivitis) Watery diarrhea Vomiting Severe muscle aches Confusion Low blood pressure A week or more after the beginning of the skin rash, the skin around the nails may begin to peel [healthychildren.org]

  […] with peeling of the skin, especially of the palms and soles, occurs during the acute phase Syndrome characterized by high fever, vomiting, diarrhea, confusion, and skin rash; almost all cases have been related to an infection with toxin-producing staphylococcus [icd9data.com]

• Flushing

  Areas that could contain the bacteria, such as surgical wounds and the vagina, are flushed out with water (irrigated). [merckmanuals.com]

  Next to the bed, there was a tube of black toxins that had been flushed out of her bloodstream. She looked out the window and saw a series of little houses outside, which her brain groggily associated with the Southwest. [vice.com]

  The amount of fluid that flowed from wide-open bottles and flushed through me in the first 24 hours 'would stagger the imagination of many physicians,' Dr. Root declared. [nytimes.com]

• Eczema

  Predisposing factors include trauma, surgery, burns and eczema, less commonly associated factors includes insect bites and subcutaneous insulin injection, an association between the use of non-steroidal anti-inflammatory and NF has been reported [ 9 ] [casesjournal.biomedcentral.com]

• Tampon Use

  When using tampons, women are advised to: Wash their hands thoroughly before inserting a tampon Use the lowest absorbency tampons for their period flow Change tampons at least as regularly as directed on the pack Avoid using more than one tampon Insert [medicalnewstoday.com]

  Doctors say all of that was caused by TSS, a bacterial infection caused by heavy tampon use in younger women. According to experts, bacteria can grow during a woman's menstrual cycle, particularly with tampon use. [aol.com]

  The link between tampons and toxic shock syndrome is strong, but their use is not the only cause. (Photo: Yulia Grigoryeva/Shutterstock) MYTH: Toxic shock syndrome only affects women who use tampons. [mnn.com]

• Oliguria

  Over the course of the next 24 to 48 h, generalized edema of face, hands and feet, arthralgias, particularly of the wrists, knees, ankles, fingers, and toes, the erythroderma, conjunctival injection, cough, dizziness and syncope, incontinence, and oliguria [scielo.br]

• Confusion

  […] vomiting, diarrhea, and myalgia, followed by hypotension and in severe cases, shock; a sunburn-like rash with peeling of the skin, especially of the palms and soles, occurs during the acute phase Syndrome characterized by high fever, vomiting, diarrhea, confusion [icd9data.com]

  Other symptoms can include confusion or other mental changes, decreased urination, fatigue and weakness, and thirst. [kidshealth.org]

  Have someone else drive, especially if the person is feeling lightheaded or confused. Women who are menstruating and using a tampon should remove the tampon prior to going to the hospital. [emedicinehealth.com]

• Headache

  Flu-like symptoms, such as headaches, chills and a sore throat can be linked to TSS. [bbc.co.uk]

  In addition, affected individuals would also exhibit signs of diarrhea, nausea, headache, low blood pressure, seizures, muscle aches, vomiting and development of redness in the eyes, throat and mouth. [symptoma.com]

  Other symptoms can include a fever of over 102 degrees, nausea, vomiting, headaches, and muscle aches. If these symptoms occur, it's important to seek medical attention as soon as possible. [medicaldaily.com]

  She complained of fever for one day with headache and abdominal pain after the fever developed. [ncbi.nlm.nih.gov]

• Dizziness

  If you experience sudden fever, vomiting, diarrhea, dizziness or muscle aches, immediately discontinue tampon use and consult with your doctor. [michigan.gov]

  These toxins cause a massive drop in blood pressure (shock), resulting in dizziness and confusion. They also damage tissue, including skin and organs, and can disturb many vital organ functions. [hse.ie]

  They include: A sunburn-like rash, and/or peeling skin A high fever Severe flu-like symptoms Headache or muscle aches Stomach cramps Sore throat Nausea or vomiting Diarrhea Weakness Dizziness, lightheadedness, or confusion Pale, clammy skin How to Reduce [pamf.org]

  WARNING SIGNS OF TSS ARE, FOR EXAMPLE, SUDDEN FEVER (USUALLY 102° F OR MORE), VOMITING, DIARRHEA, FAINTING OR NEAR FAINTING WHEN STANDING UP, DIZZINESS, OR A RASH THAT LOOKS LIKE A SUNBURN. [playtexplayon.com]

  Warning signs of TSS include: sudden high fever (usually 102ºF or more) accompanied by vomiting and/or diarrhea, fainting or near-fainting when standing up and dizziness or a sunburn-like rash. [web.archive.org]

• Altered Mental Status

  We report the case of a 45-year-old Japanese woman who on receiving chemotherapy for advanced breast cancer developed an altered mental status and dysarthria soon after fever from infection of a subcutaneous implantable port. [ncbi.nlm.nih.gov]

  The physical findings for staph TSS are fever, tachycardia, hypotension, sun burn type rash (90%), and altered mental status. [clinicaladvisor.com]

• Lethargy

  […] the areas of the body Liver impairment Shedding of the skin in large sheets, especially over the palms and soles (this does not always occur) Difficulty breathing The following are the most common symptoms of C. sordellii TSS: Nausea and/or vomiting Lethargy [hopkinsmedicine.org]

  The central nervous system examination is impressive for the confusion, agitation, or lethargy without focal findings. [scielo.br]

No single test would be helpful in diagnosing TSS. A series and combination of methods needs to be employed for appropriately diagnosing the condition. The following methods are carried out for diagnosis:

• Blood tests to determine complete blood count which would reveal leukocytosis in individuals who have developed TSS. In addition, blood cultures are carried out to determine the presence of bacteria.
• Urine analysis is done to evaluate presence of myoglobinuria and hemoglobinuria.
• Imaging studies such as CT scan and chest X-ray are also indicated to determine the functioning of various organs [8].

• Pyuria

  Laboratory findings consistent with tss include leukocytosis, elevated prothrombin time, hypoalbuminemia, hypocalcemia, and pyuria A severe illness caused by infection with staphylococcus aureus and characterized by high fever of sudden onset, vomiting [icd9data.com]

  […] phosphokinase level at least twice the upper limit of normal Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia Renal: blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria [wwwn.cdc.gov]

  Severe myalgia or creatine phosphokinase level at least twice the upper limit of normal Mucous membrane : Vaginal, oropharyngeal, or conjunctival hyperemia Renal : BUN or creatinine at least twice the upper limit of normal or urinary sediment with pyuria [lifeinthefastlane.com]

• Liver Enzymes Abnormal

  An elevated white blood cell count, elevated liver enzymes, abnormal electrolytes, and abnormal kidney function may be consistent with toxic shock syndrome. Women undergo a pelvic exam. [emedicinehealth.com]

• Staphylococcus Aureus

  […] due to methicillin susceptible Staphylococcus aureus Toxic shock syndrome due to MRSA Toxic shock syndrome due to MSSA Toxic shock syndrome due to other Staph Toxic shock syndrome due to Staphylococcus Clinical Information A rare acute life-threatening [icd9data.com]

  aureus/genetics* Staphylococcus aureus/growth & development Staphylococcus aureus/pathogenicity Superantigens/biosynthesis* Superantigens/genetics Vagina/microbiology* Substances Bacterial Toxins Enterotoxins RNA, Ribosomal, 16S Superantigens enterotoxin [ncbi.nlm.nih.gov]

  However, Staphylococcus aureus (the microbe that causes TSS) lives on the skin and in mucosal sites on the human body and can be transmitted by direct contact between people. 2 Reservoirs: Humans are the largest natural reservoir for Staphylococcus aureus [austincc.edu]

  Cause In majority of the cases, TSS is caused due to toxins produced by the bacteria Staphylococcus aureus. In many instances, a streptococcus bacteria is also responsible for causing TSS. [symptoma.com]

The primary and major goal of treatment of TSS is to restore the vital functioning of the organs of the body. Individuals may need to be hospitalized until the vital signs are under control. This would be achieved by administration of antibiotics through the intravenous route to ward off the infections. Of lately, FDA approved 3 antibiotics to be used for treatment of TSS. These include tedizolid, dalbavancin and oritavancin. These drugs are known to be active against species of Staphylococcus aureus and Streptococcus [8]. Other medications would also be employed to stabilize the patient and bring the blood pressure back to normal levels. Intravenous fluids are also administered to correct dehydration. If complications have already set in such as kidney failure then dialysis is indicated in such cases.

If the syndrome is caused due to foreign agents such as tampons or vaginal sponge, then preliminary the foreign matter would be removed. If wound from injury are cause of infection, then surgical debridement of the infected tissue is indicated. Individuals are also given gamma globulin injections which help in boosting the immunity status of the affected individuals [9] [10].

The onset of the symptoms of TSS is pretty quick and turns fatal in about 50% of cases. Early recognition of the signs of the syndrome is very important to prevent the onset of complications. Individuals who survive the condition can suffer from recurrent attacks of the syndrome.

In many instances, TSS can severely affect the functioning of various organs such as kidney, liver and heart. The development of shock due to toxin production by the bacteria can severely impair the physical and mental functioning of the affected individuals [6].

TSS can affect individuals of any age group. It is primarily caused due to toxins produced by the Staphylococcus aureus. Individuals with infections of the skin, burns, open wounds and surgery are more susceptible to contract toxic shock syndrome. The toxin producing variety of Staphylococcus aureus often target the population who are at risk of developing the syndrome [2].

TSS is a rare condition and its incidence underwent significant decline after 1980. However, rise in number of cases of TSS was reported in the year 2000. It has been estimated that the syndrome occurs in about 3 to 4 out of every 100,000 users of tampons per year [3].

For the bacterial toxins to produce effect and cause development of characteristic symptoms, the causative organism must gain entry inside the body. Once infection occurs, the bacteria produce toxins which are systemically absorbed by the human body. Manifestations of signs and symptoms of TSS occur in those individuals who do not have antitoxin antibody protective layer. Such sequence of events causes production of cytokines which in turn induce tissue injury and shock [4] [5].

Use of high absorbent tampons has a significant association with TSS. Women are therefore advised to take a careful note of this fact and discontinue the use of such tampons. Low absorbent tampons should be preferred as these should be changed every 4 to 8 hours. Prolonged usage of such absorbent tampons can increase the risk of developing TSS. Individuals who have suffered wounds or injury are advised to regularly check their wounds for signs of infection. Regular cleaning of the wound is also expected [11].

Toxic shock syndrome (TSS) can affect menstruating women as well as men and children. The condition was first described in the year 1978 in children. Research studies have pointed towards an association between use of tampons and development of TSS in menstruating women. However, the incidence of TSS has decreased in this population owing to withdrawal of highly absorbent tampons from the market.

Definition

Toxic shock syndrome (TSS) is a life threatening condition caused by bacterial infections. In the past, TSS was associated with use of highly absorbent tampons by menstruating women. However, individuals who have suffered injuries are also susceptible to develop such a kind of syndrome.

Cause

In majority of the cases, TSS is caused due to toxins produced by the bacteria Staphylococcus aureus. In many instances, a streptococcus bacteria is also responsible for causing TSS.

Symptoms

Symptoms of TSS develop suddenly and the disease progresses at a fast pace. The signs include high fever, headaches, hypotension, vomiting and diarrhea, muscle aches, confusion, seizures and rash on palm and soles.

Diagnosis

Blood and urine tests are required for diagnosis of TSS. Blood cultures will provide information regarding the type of bacteria present. In addition, imaging tests would be necessary to evaluate the function of the vital organs of the body.

Treatment

Individuals with TSS will need to be hospitalized to be closely monitored for the vital signs. In addition, antibiotics are administered for warding off the infection from the body. Foreign bodies such as tampons are the cause of infection then these are removed. If wounds are the cause then surgical debridement of the tissues would be necessary.

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