Staphylococcal Toxic Shock Syndrome



  • An acute toxin-mediated illness associated with Staphylococcus aureus infection
  • Toxic shock syndrome (TSS) is characterized by sudden onset of high fever and rash with subsequent hypotension, desquamation, and involvement of ≥3 organ systems (1):
    • Menstrual (less common): associated with menstruation and tampon use
    • Nonmenstrual (more common): associated with postoperative wounds and barrier contraception
  • Can occur in children and adults
  • System(s) affected: multiple


  • Predominant age: 15 to 35 years; can occur at any age
  • Predominant sex: female > male
  • Nonmenstrual cases increasingly associated with methicillin-resistant S. aureus (MRSA) infections and carry a higher mortality rate (1)
  • Newborn: neonatal TSS-like exanthematous disease syndrome

59 to 78 cases per year reported to the CDC from 2011 to 2015 (2)

Etiology and Pathophysiology

  • S. aureus exotoxins, especially TSS toxin-1 (TSST-1) (in >90% of menstrual cases)
  • Staphylococcal enterotoxins A to E and G to I
  • Enterotoxins B and C cause 50% of nonmenstrual TSS.
  • Production and release of staphylococcal superantigens that bind to APC MHC class II and V-β region of T-cell receptor
  • T cells are activated, releasing cytokines (interleukin [IL]-1, IL-2, γ-interferon, tumor necrosis factor [TNF]-α, TNF-β, IL-6) that cause capillary leak, hypotension, and shock.

Risk Factors

  • Use of regular absorbency tampons during menstruation
  • Surgical wound infections
  • Cellulitis
  • Early postpartum state, especially after cesarean section or episiotomy
  • Pediatric considerations
    • TSS may occur as a complication of chickenpox or burns. TSS is the most common cause of unexpected mortality after small burns in children. Prophylactic antibiotic use is not indicated in this situation (3).

General Prevention

  • Appropriate use of feminine hygiene products
  • Early attention to infected wounds

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