[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Conditions](https://durgical.com/en/conditions/) › Toxic shock syndrome [Conditions](https://durgical.com/en/conditions/) · [Infectious and tropical diseases](https://durgical.com/en/conditions/) # Toxic shock syndrome Toxic shock syndrome is a rare, sudden illness caused by bacterial toxins that bring fever, a sunburn-like rash, low blood pressure and organ failure. Updated 2026-11-01 ## Structures involved Tap one to see what it is and open it in 3D. - [Vagina](https://durgical.com/en/anatomy/vagina/) - [Skin](https://durgical.com/en/anatomy/skin/) - [Cervix](https://durgical.com/en/anatomy/cervix-of-uterus/) - [Vaginal fornix](https://durgical.com/en/anatomy/vaginal-fornix/) - [Body of uterus](https://durgical.com/en/anatomy/body-of-uterus/) - [Nasal cavity](https://durgical.com/en/anatomy/nasal-cavity/) ## Microorganisms that cause it - [Staphylococcus aureus](https://durgical.com/en/microbiology/staphylococcus-aureus/) - [Streptococcus pyogenes](https://durgical.com/en/microbiology/streptococcus-pyogenes/) ## In immunology - [T-cell activation: two signals and superantigens](https://durgical.com/en/immunology/t-cell-activation-two-signals-and-superantigens/) ## Why it happens - [Shock: types, stages and the organs it damages](https://durgical.com/en/general-pathology/shock-types-stages-and-the-organs-it-damages/) - [How septic shock develops](https://durgical.com/en/general-pathology/how-septic-shock-develops/) - [Systemic effects of inflammation: fever, acute-phase proteins, leukocytosis, sepsis](https://durgical.com/en/general-pathology/systemic-effects-of-inflammation-fever-acute-phase-proteins-leukocytosis-sepsis/) - [Shock physiology](https://durgical.com/en/physiology/shock-physiology/) - [Innate and adaptive immunity: overview](https://durgical.com/en/physiology/innate-and-adaptive-immunity-overview/) ## What it is An acute, life-threatening illness caused by superantigen toxins of Staphylococcus aureus or Streptococcus pyogenes (group A streptococcus). It presents with high fever, diffuse rash, hypotension and failure of several organs. ## Who gets it Uncommon in all regions. Menstrual staphylococcal cases fell after highly absorbent tampons were withdrawn; most cases now follow skin and soft-tissue infections, surgery, burns, childbirth or nasal packing. Streptococcal toxic shock is often linked to invasive infections such as necrotizing fasciitis and carries a higher mortality. ## Causes - Staphylococcus aureus producing toxic shock syndrome toxin-1 (TSST-1) or enterotoxins - Group A streptococcus producing pyrogenic exotoxins (streptococcal toxic shock) - A colonised or infected focus: prolonged tampon or vaginal device use, wounds, surgical sites, burns, postpartum infection, nasal packing ## Risk factors - Tampons left in place for a long time, menstrual cups, diaphragms or contraceptive sponges - Recent surgery, childbirth or abortion - Skin wounds, burns or varicella lesions (streptococcal form) - Nasal packing or other retained foreign bodies - Lack of protective antibodies against the toxin ## Pathophysiology The toxins act as superantigens: they bind MHC class II molecules and T-cell receptors outside the normal antigen site, activating a large fraction of T cells at once. The resulting cytokine storm (TNF, IL-1, IL-2, interferon) causes capillary leak, vasodilation, shock and multiorgan failure, and the skin shows a diffuse erythroderma that later desquamates. ## Classification - Staphylococcal toxic shock syndrome: menstrual and non-menstrual - Streptococcal toxic shock syndrome, usually with an invasive soft-tissue infection - Confirmed or probable case according to surveillance criteria ## Symptoms and signs - Sudden high fever with chills - Diffuse red, sunburn-like rash (erythroderma) - Low blood pressure, dizziness or fainting - Vomiting, watery diarrhoea and muscle pain - Redness of the conjunctivae, mouth, throat or [vagina](https://durgical.com/en/anatomy/vagina/) - Confusion - Peeling of the palms and soles one to two weeks later ## Red flags - Fever, rash and hypotension in a person using a tampon or after surgery or childbirth - Severe pain out of proportion at a wound or limb (possible necrotizing infection) - Falling urine output or rising creatinine - Confusion or reduced consciousness - Bleeding or bruising suggesting disseminated intravascular coagulation ## Diagnosis **Clinical** A clinical diagnosis based on fever, diffuse rash, hypotension and involvement of three or more organ systems, with later desquamation. Examination always looks for a focus: vaginal examination and removal of any device, wounds, surgical sites and nasal packing. **Tests** Blood counts, creatinine, [liver](https://durgical.com/en/anatomy/liver/) enzymes, creatine kinase, platelets and coagulation tests show multiorgan injury. Blood cultures are often positive in streptococcal disease and usually negative in staphylococcal disease; cultures of the focus (vaginal, wound) are taken. **Imaging** Not diagnostic. Ultrasound, CT or MRI look for a deep focus such as an abscess or necrotizing soft-tissue infection. ## Differential diagnosis - Septic shock from other bacteria, including meningococcaemia - Severe dengue - Leptospirosis and rickettsial infection - Scarlet fever and Kawasaki disease - Stevens-Johnson syndrome or toxic epidermal necrolysis - Drug reaction with eosinophilia and systemic symptoms (DRESS) ## Goal of treatment Restore perfusion, remove the source of toxin and stop toxin production quickly, while supporting failing organs in intensive care. ## Treatment **Acute** Aggressive intravenous fluids and vasopressors for shock, following sepsis care pathways. **Procedure** Remove tampons, packing or other devices, and drain or debride any infected focus; surgery is urgent when a necrotizing infection is present. **Medical** Intravenous antibiotics combining a cell-wall agent active against staphylococci and streptococci (with MRSA coverage where it is common) plus clindamycin or linezolid to suppress toxin production; intravenous immunoglobulin in selected severe cases. **Follow-up** Intensive care monitoring of blood pressure, urine output, [kidney](https://durgical.com/en/anatomy/kidney/) and liver function, coagulation and [skin](https://durgical.com/en/anatomy/skin/); dialysis or ventilation when needed. ## Complications - Refractory shock - Acute kidney injury - Acute respiratory distress syndrome - Disseminated intravascular coagulation - Liver injury and rhabdomyolysis - Loss of limbs or digits from ischaemia or necrotizing infection - Recurrence in staphylococcal menstrual cases ## Prognosis With fast source control and intensive care, most staphylococcal cases recover; mortality is higher in streptococcal toxic shock, especially with necrotizing infection. Staphylococcal cases can recur if exposure continues. ## Prevention - Use of the lowest-absorbency tampon needed and regular changes; alternating with pads - Careful wound and postoperative care - Prompt removal of nasal packing and other devices when no longer needed ## Test yourself Think of the answer, then tap the question to see it. ## Which two bacteria cause toxic shock syndrome? Staphylococcus aureus (TSST-1) and group A Streptococcus pyogenes (pyrogenic exotoxins). ## How do toxic shock toxins activate so many T cells? They are superantigens that bridge MHC class II and the T-cell receptor outside the antigen-binding groove, causing a cytokine storm. ## What skin sign typically appears 1 to 2 weeks after toxic shock syndrome? Desquamation (peeling) of the palms and soles. ## Why is clindamycin added in toxic shock syndrome? It inhibits bacterial protein synthesis and so suppresses toxin production. ## What is the first step at the bedside when a tampon user presents with fever, rash and shock? Remove the tampon (source control) while starting fluid resuscitation and antibiotics. [Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/toxic-shock-syndrome/) ## Related conditions - [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/) - [Necrotizing soft tissue infection (necrotizing fasciitis, gas gangrene)](https://durgical.com/en/conditions/necrotizing-soft-tissue-infection/) - [Streptococcal pharyngitis](https://durgical.com/en/conditions/streptococcal-pharyngitis/) - [Scarlet fever](https://durgical.com/en/conditions/scarlet-fever/) - [Disseminated intravascular coagulation](https://durgical.com/en/conditions/disseminated-intravascular-coagulation/) - [Acute kidney injury](https://durgical.com/en/conditions/acute-kidney-injury/) - [MRSA and other multidrug-resistant organism infections](https://durgical.com/en/conditions/mrsa-and-other-multidrug-resistant-organism-infections/) Educational information, not medical advice. For any symptom, see a health professional. Sources: [Toxic shock syndrome: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000653.htm) (MedlinePlus (U.S. National Library of Medicine), 2024). [← All conditions](https://durgical.com/en/conditions/) ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/conditions/toxic-shock-syndrome/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/toxic-shock-syndrome/