Toxic shock syndrome (TSS): symptoms and causes

Health classes in grade school usually touch on menstruation and the various products girls can use when they are on their periods. And if you’ve ever been in one of these health classes, it’s likely you remember the warnings your instructors gave you about using tampons; most notably, not to leave them in for too long so you don’t succumb to toxic shock syndrome or TSS—a rare, but potentially life-threatening illness caused by a bacterial infection that has spread to the bloodstream.The illness can cause immediate symptoms, including a fever, low blood pressure, skin rash, and upset stomach. In some cases, it can lead to organ damage and death (Billon, 2020). 

While TSS is predominantly talked about in reference to tampon use, it can actually affect anyone of any age, including men and children. So, it’s important to have an understanding of what toxic shock syndrome is, how to spot it, and what to do if you think you may have it.

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Toxic shock syndrome is an illness that results from a bacterial infection. The illness is usually caused by strains of bacteria called Streptococcus pyogenes (Group A Streptococcus) or Staphylococcus aureus (although other strains are capable of causing TSS).

These bacteria are called “superantigens” because they can produce toxins that cause higher-than-usual activation of the body’s immune system, and they can bypass T-cells, which are immune system cells that help defend the body from infection. They can also trigger damaging levels of inflammation (Ross, 2021).

This infection can become life-threatening if it spreads from the blood to the organs, where it can cause organ failure. 

Fortunately, TSS is rare. In the U.S., experts peg its incidence at between 1-3 cases per 100,000 people. If the TSS is caused by streptococcal bacteria (often referred to as STSS), the mortality rate is quite high, ranging from 30-80%. If staphylococcal or other bacteria cause the TSS, the mortality rate is not as high (Ross, 2021). 

While toxic shock syndrome is not confined to the improper use of tampons, it is what most people associate toxic shock syndrome with—so let’s start there. 

One study found that using the same tampon for more than eight consecutive hours while sleeping overnight can increase the risk of TSS (sometimes referred to as menstrual toxic shock syndrome or mTSS). However, that risk remains very small (Billon, 2020). 

So, how does this happen? When someone leaves a tampon or menstrual cup in for too long, the bacteria that cause TSS are able to grow rapidly and can reach the bloodstream—for example, through a small cut or abrasion inside the vagina (Nonfoux, 2018). 

While this form of TSS is rare, the strains of bacteria that cause mTSS are quite common. Some researchers have found that roughly 1-5% of women who use tampons have one or more types of these bacteria in their vaginal tracts. But, rest assured that simply having these strains and risk factors does not mean that you will develop TSS (Billon, 2020). 

Aside from not using menstrual products correctly, there are other ways someone may be at risk for TSS. In fact, while menstrual TSS generates a lot of attention, infants and the elderly are most at risk for this condition (Ross, 2021). In these groups, TSS can result from bacteria contamination following a surgery or other medical procedure like dialysis. Experts often don’t know how the bacteria get into the body of people with TSS, and while like an injury or surgical wound are obvious reasons, the bacteria may also get into the body through the skin inside the nose and throat.

Burns or other unclean skin wounds (which can lead to skin infection), postpartum infections, and post-flu pneumonia can also lead to TSS. Also, any “foreign bodies” left inside of your body—not just tampons, but also nasal packing—can cause toxic shock syndrome (Burnham, 2015).   

Toxic shock syndrome symptoms usually appear within a few days and may include a high fever, chills, fatigue, muscle aches or pain, confusion, a strawberry-red tongue, and a red skin rash that tends to start on the trunk of the body and then moves out to the limbs (Billon, 2020; Burnham, 2015). 

According to a study from France, the most common signs of toxic shock syndrome in people with menstrual TSS (i.e. in people who developed TSS from tampons) were (Billon, 2020; Ross, 2021):

• A fever higher than 102 degrees

• Hypotension (low blood pressure), which can cause confusion, dizziness, fatigue, a rapid pulse, and shallow breathing

• A red sunburn-like rash

• Sore throat

• Upset stomach or digestive problems 

As TSS progresses, it can affect the function of the kidneys, heart, liver, and other organs, producing an array of symptoms (Ross, 2021). 

The symptoms of TSS are considered “non-specific.” That means a wide range of health conditions can cause them. By themselves, they don’t indicate TSS. To complicate matters further, there is not a specific test designed to diagnose someone with the illness, so healthcare providers may need to rule out other illnesses first (Burnham, 2015;  Ross, 2021).

Some of tests your healthcare provider may conduct to determine if you have TSS include (Ross, 2021):

• Blood tests like a complete blood count (CBC) and a comprehensive metabolic panel (CMP) to check for higher-than-normal levels of various substances and cells in the blood

• Blood cultures to look for bacteria in the blood

• Lumbar puncture (spinal tap)—a procedure that involves inserting a needle into the area around your spine—to rule out meningitis 

Because toxic shock syndrome can be life-threatening, it is considered a medical emergency that requires immediate treatment, usually within an intensive care unit (ICU). 

This treatment will almost always involve some combination of intravenous (IV) fluid hydration and antibiotics. The specific antibiotic may vary depending on the type of bacteria that’s causing the infection. Blood tests can help your health care provider figure this out (Ross, 2021).

Other drugs may also be necessary to help control or counteract the organ failure, TSS rash, or additional symptoms. In some cases, surgery or other more extreme interventions may be necessary. 

And, while uncommon, TSS can be contagious. It is considered an infectious disease, and people who are exposed to someone with TSS (such as household members) may require medical observation (Ross, 2021).

Improper tampon use seems to be one of the biggest risk factors for TSS. It’s important to closely follow the instructions related to the use of tampons and menstrual cups; that means using these products only as directed on the box—and for no more than eight hours at a time. (Some researchers have found evidence that reducing this to six hours may halve the risk of mTSS.) 

Another form of prevention is using pads in place of tampons. Getting TSS from pads, while not thoroughly researched, is unlikely. Most of the research on mTSS has linked it to the use of intra-vaginal devices—meaning those that are inserted into the vagina (like tampons) (Billon, 2020).  

Outside of menstrual cases, TSS is often caused by surgical wound infection or other scenarios that are mostly outside of a person’s control. Considering that TSS is rare, there’s not much you can do to lower your already-very-low risk for the condition (Ross, 2021). 

At the end of the day, TSS is uncommon, but it is still a medical emergency. Early treatment can safe lives, so if you think you may be experiencing symptoms of TSS, it is important to seek emergency treatment immediately. 

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Current version

January 25, 2022

Written by

Health Guide Team

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.