TOXIC SHOCK SYNDROME

Staphylococcal and streptococcal toxic shock syndromes (TSS) are acute-onset multiorgan illnesses defined by the criteria listed in Tables 18.1 and 18.2. Staphylococcal TSS is caused by Staphylococcus aureus strains that make pyrogenic toxin superantigens (PTSAgs); coagulase-negative strains do not make the causative toxins. Streptococcal TSS is caused mainly by toxin-producing group A strains but occasionally by groups B, C, F, and G strains. Several subsets of staphylococcal TSS exist, with two major categories being menstrual and nonmenstrual.

Menstrual TSS (Figure 18.1), which occurs within a day or two of and during menstruation, primarily has been associated with use of certain tampons, notably those of high absorbency, and is associated with production of TSS toxin-1 (TSST-1) by the causative bacterium. Three theories have been proposed to explain the role of tampons in menstrual TSS: (1) Tampons introduce oxygen, which is required for production of TSST-1, into the vagina; (2) tampons bind magnesium, which alters growth kinetics of S. aureus and thus alters the time when TSST-1 is made; and (3) pluronic L-92, a surfactant present in the Rely tampon, which was highly associated with TSS, amplifies production of TSST-1. Certain other surfactants may have similar effects.

Nonmenstrual TSS occurs in both males and females, adults and children, and it is associated with S. aureus strains that make TSST-1 or staphylococcal enterotoxins, notably enterotoxin serotypes B and C. The illness occurs in association with nearly any kind of staphylococcal infection, but major forms have been identified: postsurgical, influenza associated, RED syndrome (see below), and occasionally with use of contraceptive diaphragms.