Toxic Shock Syndrome

by James K. Todd, M.D.
Professor of Pediatrics, Microbiology and Preventive Medicine
University of Colorado School of Medicine
Denver, Colorado

What is Toxic Shock Syndrome?

Toxic Shock Syndrome (TSS) is an acute, severe disease that is characterized by fever, shock, and a sunburn-like rash. TSS is commonly associated with females who are menstruating and using tampons, but it can occur in boys and girls of any age. Fortunately, if recognized early, TSS can be successfully treated.


What causes Toxic Shock Syndrome?

TSS is caused by a toxin (i.e., a poison) at the site of an infection in the body produced by a bacterial organism called Staphylococcus aureus. This organism commonly causes wound infections and abscesses in children. The growth conditions at the site of the infection (which also can occur in adolescent girls who are menstruating and using tampons) provide the organism with the proper nutrients to produce a potent toxin that circulates throughout the body.


Who gets Toxic Shock Syndrome?

Boys and girls of any age can get TSS. It is not just a disease associated with tampons; however, any tampon brand or type, or other inserted vaginal device (e.g., a contraceptive sponge or a diaphragm), can cause the disease if it catches the right patient at the right time. Even so, most children will never be at risk of getting TSS, because they have already developed immunity to the toxin.


How does the toxin cause disease?

A toxin produced at the site of the infection can get into the bloodstream and then go to all of the organs of the body. It damages the blood vessels, and they leak fluid into the tissues. This fluid loss can lead to shock, as well as injury to many organs, including the skin, kidney, liver, brain, and heart.


What are the common findings?

TSS begins with a fever, nausea and vomiting, diarrhea, and a sore throat. The symptoms of TSS are very similar to many other less severe and more common childhood illnesses. However, TSS then progresses to a sunburn-like rash, with signs of early shock, which may be characterized by dizziness, fainting, or confusion.


How is Toxic Shock Syndrome diagnosed?

Doctors diagnose TSS by examining the patient and noting the common signs of the disease in the presence of menstruation and tampon use, or a possible site of bacterial infection, such as a wound infection or an abscess. TSS should be suspected in boys and girls of any age who have a fever or a possible Staphylococcus infection (e.g., a wound infection, an abscess, or a boil), and any of the following symptoms: sunburn-like rash; fainting, dizziness, or confusion; or menstruation and tampon use.


How is Toxic Shock Syndrome treated?

TSS is treated by administering antibiotics to kill the organism, and cleansing the site of the infection (i.e., removal of a tampon or other vaginal device in girls who are menstruating, or surgical drainage if an abscess or a wound infection is present). Patients are admitted to the hospital and given intravenous fluids. If organ failure occurs, patients may be treated with other medications.


What are the complications?

Most children with TSS survive, especially if the disease is treated early in its course. Less than 5% of cases are fatal. Most patients will have peeling of the skin on their fingers and toes after several weeks, and, a month later, some transient hair loss may occur. Adolescent girls may experience increased swelling of the hands and feet during menstruation for several months. Some girls may have recurrences of TSS if they use tampons during menstruation in the six months after their first episode.


How can Toxic Shock Syndrome be prevented?

Early recognition and treatment is important. Adolescent girls should be encouraged to use the lowest absorbency tampon that will still control their flow, to change tampons frequently (every four to six hours), and to use pads instead of tampons at night. Although it has been claimed that "all-cotton" tampons have a lower risk of TSS, this is probably not true. A menstruating girl who develops any of the symptoms of TSS (see Table 1) should remove the tampon and immediately seek medical attention.


What research is being done?

Current research shows that TSS is being recognized earlier in its course; therefore, it is being treated more effectively. This has resulted in a decreased fatality rate and less complications. Adolescent girls should be encouraged to read and heed the information regarding TSS on tampon boxes, to learn the warning signs, and to always remove a tampon. If adolescent girls have any symptoms or concerns, they should seek medical attention. Tampon manufacturers are working to make product improvements that will further minimize the already low risk of contracting TSS.


Links to other information

For more information on TSS, log on to the following Web sites:, Toxic Shock



Kurtz B, Combs P, Todd A, Anderson J, Todd J. Epidemiology of toxic shock syndrome in Colorado, 1970-1996. Royal Society of Medicine Int Congress Symp. 1998; 229: 24-26.

Todd JK, Todd BH, Franco-Buff A, Smith C, Lawellin DW. Influence of focal infection conditions on the pathogenesis of toxic shock syndrome. J Infect Dis 1987;155:673-81.

Todd JK. Toxic shock syndrome. In: Principles & Practice of Pediatric Infectious Diseases, 1996.

Copyright 2012 James K. Todd, M.D., All Rights Reserved