Toxic shock syndrome: Wikis

  
  

Note: Many of our articles have direct quotes from sources you can cite, within the Wikipedia article! This article doesn't yet, but we're working on it! See more info or our list of citable articles.

Encyclopedia

From Wikipedia, the free encyclopedia

Toxic shock syndrome
Classification and external resources
ICD-10 A48.3
ICD-9 040.82
DiseasesDB 13187
eMedicine med/2292 emerg/600 derm/425 ped/2269
MeSH D012772

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 bacteria include Staphylococcus aureus and Streptococcus pyogenes. Streptococcal TSS is sometimes referred to as toxic shock-like syndrome (TSLS) or Streptococcal Toxic Shock Syndrome (STSS).

Contents

Routes of infection

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 bacteria's pervasiveness and presence in normal flora, minor cuts and such allow natural immunization on a large scale.

It is believed that approximately half the cases of staphylococcal TSS reported today are associated with tampon use during menstruation. However, TSS can also occur in children, men, and non-menstruating women.

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 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).[2] Tampons made with rayon do not appear to have a higher risk of TSS than cotton tampons of similar absorbency.[3]

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 are provided by the tampon that is inserted into the normally anaerobic vaginal environment.[1] 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.[4] 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 a menstrual cup or sanitary napkin.

Incidence

Staphylococcal toxic shock syndrome is rare and the number of reported cases has declined significantly since the 1980s. Patrick Schlievert, who published a study on it in 2004, determined incidence at 3 to 4 out of 100,000 tampon-using females per year; the information supplied by manufacturers of sanitary products such as Tampax and Stayfree puts it at 1 to 17 of every 100,000 menstruating females per year.[5][6] The CDC has stopped tracking TSS. However, there was a rise in reported cases in the early 2000s: eight deaths from the syndrome in California in 2002 after three successive years of four deaths per year, and Schlievert's study found that cases in part of Minnesota more than tripled from 2000 to 2003.[5] Schlievert considers earlier onset of menstruation to be a cause of the rise; others, such as Philip M. Tierno, blame new high-absorbency tampons introduced in 1999 and manufacturers discontinuing warnings not to leave tampons in overnight.[5]

History

Initial description of toxic shock syndrome

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 in 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. But 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. Many cases of TSS occurred after tampons were left in the woman using them.[8]

Rely tampons

Package of Rely Tampons

Following a controversial period of test marketing in Rochester, New York and Fort Wayne, Indiana,[9] in August 1978 Procter and Gamble introduced superabsorbent Rely tampons to the United States market[10] in response to women's demands for tampons that could contain an entire menstrual flow without leaking or replacement.[2] Rely used carboxymethylcellulose (CMC) and compressed beads of polyester for absorption. This tampon design could absorb nearly 20 times its own weight in fluid.[11] Further, the tampon would "blossom" into a cup shape in the vagina in order to hold menstrual fluids without leakage.

In January 1980, epidemiologists in Wisconsin and Minnesota reported the appearance of TSS, mostly in menstruating women, to the CDC.[12] S. aureus was successfully cultured from most of the women. A CDC task force investigated the epidemic as the number of reported cases rose throughout the summer of 1980, accompanied by widespread publicity. In September 1980, the CDC reported that users of Rely were at increased risk for developing TSS.[13]

On September 22, 1980, Procter and Gamble recalled Rely[14] following release of the CDC report. As part of the voluntary recall, Procter and Gamble entered into a consent agreement with the FDA "providing for a program for notification to consumers and retrieval of the product from the market."[15] However, it was clear to other investigators that Rely was not the only culprit. Other regions of the United States saw increases in menstrual TSS before Rely was introduced.[16] It was shown later that higher absorbency of tampons was associated with an increased risk for TSS, regardless of the chemical composition or the brand of the tampon. The sole exception was Rely, for which the risk for TSS was still higher when corrected for its absorbency.[17] The ability of carboxymethylcellulose to filter the S. aureus toxin that causes TSS may account for the increased risk associated with Rely.[11]

By the end of 1980, the number of TSS cases reported to the CDC began to decline. The reduced incidence was attributed not only to the removal of Rely from the market, but also to reduced use of all tampon brands. According to the Boston Women's Health Book Collective, 942 women were diagnosed with tampon-related TSS in the USA from March 1980 to March 1981, 40 of whom died.

Symptoms and diagnosis

Symptoms of toxic shock syndrome vary depending on the underlying cause. TSS resulting from infection with the bacteria Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress to stupor, coma, and multi-organ failure. The characteristic rash, often seen early in the course of illness, resembles a sunburn, and can involve any region of the body, including the lips, mouth, eyes, palms and soles. In patients who survive the initial onslaught of the infection, the rash desquamates, or peels off, after 10–14 days.

In contrast, TSS caused by the bacteria Streptococcus pyogenes, or TSLS, typically presents in people with pre-existing skin infections with the bacteria. These individuals often experience severe pain at the site of the skin infection, followed by rapid progression of symptoms as described above for TSS. In contrast to TSS caused by Staphylococcus, Streptococcal TSS less often involves a sunburn rash.

In either case, diagnosis is based strictly upon CDC criteria modified in 1981 after the initial surge in tampon-associated infections.[18]:

  1. Body temperature > 38.9 °C (102.02 °F)
  2. Systolic blood pressure < 90 mmHg
  3. Diffuse rash, intense erythroderma, blanching ("boiled lobster") with subsequent desquamation, especially of the palms and soles
  4. Involvement of three or more organ systems:

Pathogenesis

In both TSS (caused by Staph. aureus) and TSLS (caused by Strep. pyogenes), disease progression stems from a superantigen toxin that allows the non-specific binding of MHC II with T cell receptors, resulting in polyclonal T cell activation. In typical T cell recognition, an antigen is taken up by an antigen-presenting cell, processed, expressed on the cell surface in complex with class II major histocompatibility complex (MHC) in a groove formed by the alpha and beta chains of class II MHC, and recognized by an antigen-specific T cell receptor. By contrast, superantigens do not require processing by antigen-presenting cells but instead interact directly with the invariant region of the class II MHC molecule. In patients with TSS, up to 20% of the body's T cells can be activated at one time. This polyclonal T-cell population causes a cytokine storm, followed by a multisystem disease. The toxin in S. aureus infections is Toxic Shock Syndrome Toxin-1, or TSST-1.

Treatment and prognosis

The severity of this disease frequently warrants hospitalization. Admission to the intensive care unit is often necessary for supportive care (for aggressive fluid management, ventilation, renal replacement therapy and inotropic support), particularly in the case of multiple organ failure.[19] The source of infection should be removed or drained if possible: abscesses and collections should be drained. Women wearing a tampon at the onset of symptoms should remove it immediately. Outcomes are poorer in patients who do not have the source of infection removed.[19]

Antibiotic treatment should cover both S. pyogenes and S. aureus: this may include a combination of cephalosporins, penicillins or vancomycin. The addition of clindamycin[20] or gentamicin[21] reduces toxin production and reduces mortality.

With proper treatment, patients usually recover in two to three weeks. The condition can, however, be fatal within hours.

See also

References

  1. ^ a b McCormick J, Yarwood J, Schlievert P (2001). "Toxic shock syndrome and bacterial superantigens: an update". Annu Rev Microbiol 55: 77–104. doi:10.1146/annurev.micro.55.1.77. PMID 11544350. 
  2. ^ a b Citrinbaum, Joanna (Oct. 14, 2003). "The question's absorbing: 'Are tampons little white lies?'". The Digital Collegian. http://www.collegian.psu.edu/archive/2003/10/10-14-03tdc/10-14-03dscihealth-01.asp. Retrieved 2006-03-20. 
  3. ^ Parsonnet J, Modern P, Giacobbe K (1996). "Effect of tampon composition on production of toxic shock syndrome toxin-1 by Staphylococcus aureus in vitro". J Infect Dis 173 (1): 98–103. PMID 8537689. 
  4. ^ Schlievert P, Jablonski L, Roggiani M, Sadler I, Callantine S, Mitchell D, Ohlendorf D, Bohach G (2000). "Pyrogenic toxin superantigen site specificity in toxic shock syndrome and food poisoning in animals". Infect Immun 68 (6): 3630–4. doi:10.1128/IAI.68.6.3630-3634.2000. PMID 10816521. 
  5. ^ a b c Julie Sevrens Lyons/Knight Ridder Newspapers, "A New Generation Faces Toxic Shock Syndrome," The Seattle Times, January 25, 2005, http://seattletimes.nwsource.com/html/health/2002160362_healthtoxicshock26.html, accessed April 8, 2009, first published as "Lingering Risk," San Jose Mercury News, December 13, 2004
  6. ^ "Stayfree - FAQ About Toxic Shock Syndrome (TSS)". 2006. http://www.stayfree.com/faq_TSS.jsp. Retrieved 2006-10-13. 
  7. ^ Todd J, Fishaut M, Kapral F, Welch T (1978). "Toxic-shock syndrome associated with phage-group-I staphylococci". Lancet 2 (8100): 1116–1118. doi:10.1016/S0140-6736(78)92274-2. PMID 82681. 
  8. ^ Todd J (1981). "Toxic shock syndrome--scientific uncertainty and the public media". Pediatrics 67 (6): 921–923. PMID 7232057. 
  9. ^ Finley, Harry. "Rely Tampon: It Even Absorbed the Worry!". Museum of Menstruation. http://www.mum.org/Rely.htm. Retrieved 2006-03-20. 
  10. ^ Hanrahan S (1994). "Historical review of menstrual toxic shock syndrome". Women Health 21 (2-3): 141–65. doi:10.1300/J013v21n02_09. PMID 8073784. 
  11. ^ a b Vitale, Sidra (1997). "Toxic Shock Syndrome". Web by Women, for Women. http://www.io.com/~wwwomen/menstruation/tss.html. Retrieved 2006-03-20. 
  12. ^ CDC 1980. "Toxic-shock syndrome--United States." MMWR 29(20):229-230.
  13. ^ CDC 1980. "Follow-up on toxic-shock syndrome." MMWR 29(37):441-445.
  14. ^ Hanrahan S (1994). "Historical review of menstrual toxic shock syndrome". Women Health 21 (2-3): 141–165. doi:10.1300/J013v21n02_09. PMID 8073784. 
  15. ^ Kohen, Jamie (2001). "The History and Regulation of Menstrual Tampons". RTF document. http://leda.law.harvard.edu/leda/data/359/Kohen.html. Retrieved 2006-03-30. 
  16. ^ Petitti D, Reingold A, Chin J (1986). "The incidence of toxic shock syndrome in Northern California. 1972 through 1983". JAMA 255 (3): 368–72. doi:10.1001/jama.255.3.368. PMID 3941516. 
  17. ^ Berkley S, Hightower A, Broome C, Reingold A (1987). "The relationship of tampon characteristics to menstrual toxic shock syndrome". JAMA 258 (7): 917–20. doi:10.1001/jama.258.7.917. PMID 3613021. 
  18. ^ Case Definitions for Public Health Surveillance
  19. ^ a b Zimbelman J, Palmer A, Todd J. "Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection". Ped Infect Dis J 18 (12): 1096–1100. http://www.pidj.org/pt/re/pidj/abstract.00006454-199912000-00014.htm;jsessionid=JZ2WwJhpv8J4dh2nDJWTywCFB4Lyy8L6Xw61G1hMCl2jYXBhQGp2!-2118404334!181195629!8091!-1. 
  20. ^ Schlievert PM, Kelly JA (1984). "Clindamycin-induced suppression of toxic-shock syndrome-associated exotoxin production". J Infect Dis 149 (3): 471. 
  21. ^ van Langevelde P, van Dissel JT, Meurs CJ, Renz J, Groeneveld PH (1 August 1997). "Combination of flucloxacillin and gentamicin inhibits toxic shock syndrome toxin 1 production by Staphylococcus aureus in both logarithmic and stationary phases of growth". Antimicrob Agents Chemother 41 (8): 1682–1685. PMID 9257741. http://aac.asm.org/cgi/content/abstract/41/8/1682. 

External links

For more information on Toxic Shock Syndrome - visit http://www.tssis.com/








Got something to say? Make a comment.
Your name
Your email address
Message