Toxic Shock Syndrome
By Keshini Sivaprakasapillai
Disease/EtiologicalAgents
ToxicShockSyndrome(TSS)–Staphylococcusaureus,Streptococcuspyogenes
Transmission
Staphylococcusaureus
Women who use super-absorbent tampons, use diaphragms or contraceptive sponges, may
haverecentlygivenbirth,hadamiscarriageoranabortion(1).Otherindividualatriskinclude
thosewhohaveundergonesurgery,ormayhavealocalinfectionintheskinordeeptissue(1).
Streptococcuspyogenes
Transmitted via respiratory droplets from an infected individual to a new host. Can also be
transmitted through direct contact with infected nasal discharge. Can be transferred via
contaminatedfood,suchasunpasteurizedmilkfromcowsthatcontainthebacterium(4).
Reservoirs
Staphylococcusaureus
Normal flora in children and adults. Specifically found in the nasal cavity, oral cavity and
gastrointestinaltract.
Streptococcuspyogenes
Humansaretheprimaryreservoir,althoughcattlecanalsoactasareservoir(4).
GeneralCharacteristicsofMO
Staphylococcusaureus
Gram-positivestaphylococci.DifferentiatedfromStaphylococcusepidermidisbybeingyellowin
colour. S. aureus is a facultative anaerobe, producing lactic acid when cultured in anaerobic
conditions. It is oxidase-negative, catalase-positive and a halophile, able to grow in
environmentswithasaltconcentrationashighas15%(2)
Streptococcuspyogenes
Gram-positive, Group A streptococci. It is a catalase-negative, facultative anaerobe. It is
classified as a Group A streptococcus because it has a hyaluronic capsule and exhibits beta
hemolysisonabloodagar(3).
Keytestsusedinidentification
In determining if TSS is caused by Staphylococcus aureus or Streptococcus pyogenes an
importanttestisacatalasetest.S.aureusiscatalase-positiveandwillthusimmediatelyproduce
bubbles (oxygen) when subjected to 3% hydrogen peroxide. S. pyogenes is catalase-negative,
andwillnotproduceanybubbles(2).AGramstaincanalsobeperformedandthemorphology
of the microorganisms can be used to differentiate between S. aureus, which will appear in
clusters,andS.pyogenes,whichwillappearinlongchains(2)(3).
VirulenceFactors
Staphylococcusaureus
S.aureuspromotescolonizationofhosttissueviasurfaceproteinsandevadesphagocytosiswith
the presence of capsules. They produce membrane-damaging toxins such as leukotoxins and
hemolysinsthataidinthelysisofeukaryoticcells.Theyalsoproduceexotoxins,specificallytoxic
shocksyndrome1(TSST-1)(8),whichdisplaysthecharacteristicsymptomsofthediseaseinthe
host(2).
Streptococcuspyogenes
S. pyogenes display M proteins which aid in adherence. These M proteins along with a
hyaluroniccapsulepreventphagocytosisbythehost’sdefenses.LikeS.aureus,S.pyogenes also
producesexotoxinsthatresultinthesymptomstypicalofTSS(3).
SignsandSymptomsofdisease
SignsandSymptomsofTSSbyS.aureusinclude(1):
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Feverhigherthan38.9°C
Flat,red,rashthatcoversmostofbody
Sheddingofskininlargesheets–specificallyonpalmsandsoles
o Seentwoweeksafteronsetofsymptoms
Lowbloodpressure,vomiting,diarrhea
Chills,headaches,fatigues
Decreasedurineoutputandsedimentinurine
Decreasedliverfunction
Lowbloodplateletcountindicatedbybruising
Disorientationandconfusion
Difficultybreathing
Increasedbloodflowtoeyesmouthandvaginacausingthemtoappearred
SignsandsymptomsofTSSbyS.pyogenesinclude(1):
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Dangerouslylowbloodpressure
Decreasedkidneyandliverfunction
Lowbloodplateletcountindicatedbybruising
Red,flat,rashcoveringmostofbody
Difficultybreathing
History
Staphylococcusaureus
TSS due to S. aureus was an epidemic in the 1980s with an incidence of 10 cases/100 000
women(9).Overthefollowing6years,thatincidencedecreasedby90%to1caseforevery100
000women(8).
Streptococcuspyogenes
EpidemicsofGroupAStreptococcuspyogeneswereseeninItalyandSpainthe1600swiththe
outbreakofscarletfever.TheinfectionsurgedagainduringWorldWarIIasrheumaticfever(5).
Control,TreatmentandPrevention
Staphylococcusaureus
S. aureus may or may not be methicillin-resistant. For strains showing susceptibility to
methicillin, a combination of the antibiotic clindamycin with oxacillin is an effective treatment
against infection. For methicilin-resistant strains of S. aureus a combination of a glycopeptide
andantibioticsuchasvancomycinandclindamycinmaybeeffective(6).
TSS can be prevented through hygienic feminine care. It is important for women to use lowabsorbencytampons,changingthemoften.Whenusingcontraceptivesitisimportanttofollow
the instructions provided by the manufacturer and never leave them in longer than
recommended(7).
Streptococcuspyogenes
S.pyogenesshowssusceptibilitytoantibiotics.Itcanbetreatedwithpenicillinandclindamycin.
Penicillin proves to be effective when given soon after infection is acquired, but less so when
organism is given time to grow to large numbers within the host. Clindamycin demonstrates
highefficacyevenwhentreatmentisdelayed(5).
Group A Streptococcus pyogenes infection can be prevented by proper wound care after
surgery(1).
LocalandGlobalCases
PrevalenceintheUnitedStateshasbeenonasteadydeclinesincethe1980swithacumulative
incidence of no more than 0.5 cases /100 000 persons (9). Globally, TSS has a prevalence of
3/100000persons(10).
References
1. ToxicShockSyndrome(TSS).JohnHopkinsMedicinHealthLibrary.Nodate
listed.VisitedMay9,2016.
http://www.hopkinsmedicine.org/healthlibrary/conditions/adult/infectious_dise
ases/toxic_shock_syndrome_tss_85,P00653/
2. StaphylococcusaureusandStaphyloccocalDisease.KennethTodar,PhD.Nodate
listed.VisitedMay9,2016.http://textbookofbacteriology.net/staph.html
3. StreptococcuspyogenesandStreptococcalDisease.KennethTodar,PhD.Nodate
listed.VisitedMay9,
2016.http://textbookofbacteriology.net/streptococcus.html
4. Streptococcuspyogenes-PathogenSafetyDataSheets.PublicHealthAgencyof
Canada.February18,2011.VisitedMay10,2016.http://www.phacaspc.gc.ca/lab-bio/res/psds-ftss/strep-pyogenes-eng.php
5. StreptococcalToxic-ShockSyndrome:SpectrumofDisease,Pathogenesis,and
NewConceptsinTreatment.DennisL.Stevens.December20,2010.VisitedMay
10,2016.http://wwwnc.cdc.gov/eid/article/1/3/95-0301_article
6. ToxicShockSyndrome(TSS).LarryM.Bush,MDandMariaT.Perez,MD.
February2016.VisitedMay10,2016.
http://www.merckmanuals.com/professional/infectious-diseases/gram-positivecocci/toxic-shock-syndrome-(tss)#v1005718
7. ToxicShockSyndrome-Prevention.NHSChoices.March3,2014.VisitedMay10,
2016.http://www.nhs.uk/Conditions/Toxic-shocksyndrome/Pages/Prevention.aspx
8. PrevalenceofToxicShockSyndromeToxin1-ProducingStaphylococcusaureus
andthePresenceofAntibodiestoThisSuperantigeninMenstruatingWomen.
JefferyParsonnet,etal.September2005.VisitedMay10,2016.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234102/
9. ToxicShockSyndromeintheUnitedStates:SurveillanceUpdate,1979-1996.
CenterforDiseaseControlandPrevention.December16,2010.VisitedMay10,
2016.http://wwwnc.cdc.gov/eid/article/5/6/99-0611_article
10. ManagingToxicShockSyndromewithAntibiotics.D.Annaneetal.August2004.
VisitedMay10,2016.
http://www.ncbi.nlm.nih.gov/pubmed/15264985?dopt=Abstract