Toxic Shock Syndrome

Table of Contents

Disease Information

Toxic shock syndrome (TSS) is a serious complication of infection with strains of Staphylococcus aureus.

Overview

Also known as:  TSS

Responsibilities

  • Hospital: Report by IDSS, facsimile, mail, or phone.
  • Infection Preventionist: Report by IDSS, facsimile, mail, or phone. Assists with case investigation
  • Lab: Report by IDSS, facsimile, mail, or phone.
  • Physician: Report by facsimile, mail, or phone.
  • Local Public Health Agency(LPHA):  Report by IDSS, facsimile, mail, or phone.

Iowa Department of Public Health
Disease Reporting Hotline: (800) 362-2736
Secure Fax: (515) 281-5698

A. Agent

Toxic shock syndrome (TSS) is a serious complication of infection with strains of Staphylococcus aureus that produce TSS toxin-1 (TSST-1) or strains of Streptococcus pyogenes that produce pyrogenic exotoxin A. S. pyogenes is more commonly known as group A streptococcus (GAS).

B. Clinical Description

TSS is a severe toxin-mediated illness with sudden onset of high fever, vomiting, profuse watery diarrhea, and myalgia, followed by hypotension and potentially shock. During the acute phase of the illness, a “sunburn-like” rash is present. One to two weeks after onset, desquamation of the skin occurs, especially on the soles and palms. Typically, the fever is higher than 102°F, the systolic blood pressure is <90 mm Hg and three or more of the following organ systems are involved:

  • gastrointestinal,
  • muscular,
  • mucous membranes (including vagina, pharynx, conjuctiva),
  • renal,
  • hepatic,
  • respiratory,
  • hematologic, or
  • central nervous system.

Blood, cerebrospinal fluid and throat cultures are negative for pathogens other than S. aureus or GAS. Rocky Mountain spotted fever, leptospirosis and measles should be ruled out. TSS can be fatal.

C. Reservoirs

Humans are the primary reservoir for both S. aureus and GAS.

D. Modes of Transmission

While TSS itself is not communicable from person-to-person, the organisms that cause TSS are. S. aureus is transmitted from person-to-person through direct contact with lesions or contaminated respiratory secretions. Airborne transmission is rare but has been documented in small children with respiratory disease.

GAS is transmitted from person-to-person through large respiratory droplets or direct contact with infected lesions. GAS can also be transmitted through ingestion of contaminated food, most commonly eggs, milk and milk products, resulting in outbreaks of GAS pharyngitis.

With both S. aureus and GAS, indirect contact through objects is rarely associated with illness, but it has occurred in schools through contaminated wrestling mats and in child care centers through play food and other shared toys.

E. Incubation period

The incubation period for S. aureus infection is variable, with a 4 - 10 day average. For GAS infection it approximately 1 to 3 days. The median incubation period for post-surgical TSS is 2 days.

F. Period of Communicability or Infectious Period

TSS itself is not communicable from person-to-person. With S. aureus, the infectious period lasts as long as lesions drain or the carrier state exists. In untreated, uncomplicated GAS cases, the infectious period may be 10 - 21 days; if purulent discharge is present, the infectious period may be extended to weeks or months. Persons with untreated GAS pharyngitis may carry and transmit the bacteria for weeks or months, with decreasing contagiousness 2 - 3 weeks after illness onset.

G. Epidemiology

In 1980, TSS became widely recognized when an association between TSS and the use of tampons was established. Since that time, the proportion of TSS cases associated with menstruation has decreased. Cases of TSS have been associated with childbirth, abortions, vaginal infections, surgical wound infections, focal lesions of the bone or respiratory tract, and cutaneous or subcutaneous lesions. The source of infection is unknown in up to one-third of cases. Cases are seen in both males and females.

Persons considered at risk for TSS include: 1) menstruating women using tampons or other inserted vaginal devices (such diaphragms or contraceptive sponges), and 2) persons with focal S. aureus or GAS infections.

H. Bioterrorism Potential

None.

I. Additional Information

The Council of State and Territorial Epidemiologists (CSTE) surveillance case definitions for Toxic Shock Syndrome can be found at:  www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm#top

CSTE case definitions should not affect the investigation or reporting of a case that fulfills the criteria in this chapter. (CSTE case definitions are used by the state health department and the CDC to maintain uniform standards for national reporting.)

References

American Academy of Pediatrics. 1997 Red Book: Report of the Committee on Infectious Diseases, 24th Edition. Illinois, American Academy of Pediatrics, 1997.

CSTE Position Statement Number: 10-ID-14

Heymann, D.L., ed. Control of Communicable Diseases Manual, 19th Edition. Washington, DC, American Public Health Association, 2008.