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Microbiology Pathology

Pathogenesis of Toxic Shock Syndrome (TSS)

  • December 30, 2010
  • 2 min read
Pathogenesis of Toxic Shock Syndrome (TSS)

Toxic shock syndrome (TSS) is a toxin mediated, rare, life threatening, systemic illness caused due to infection of Staphylococcus aureus (staphylococcal toxic shock) and Streptococcus pyogens (rarer called streptococcal toxic shock). While the syndrome often occurs in menstruating women, it can also affect men, children and postmenopausal women.

Sources of infection:

  1. Vagina (superabsorbent tampon use)
  2. Barrier contraceptives (diaphragm or vaginal sponge)
  3. Nose (nasal packing)
  4. Surgical wound
  5. Childbirth
  6. Any skin wound, such as those from chickenpox

Pathogenesis of Toxic Shock Syndrome:

Pathogenesis of Toxic Shock Syndrome

a. Bacterial Colonization:

  • TSS is initiated with the localized growth of toxin-producing strains of S.aureus in vagina or a wound

b. Exotoxin production:
Colonization is followed by the production and release of one or more pyrogenic exotoxins which acts as superantingen.
Toxins involved:

  • Major: TSST-1 (Toxic Shock Syndrome Toxin -1), Staphylococcal enterotoxin B
  • Minor: Entertoxins A, C, D, E

c. Immune response:

  1. Pyrogenic exotoxins behave as superantigens
  2. They don’t require processing by antigen presenting cells (APCs) but directly interact with class II MHC molecules
  3. Binding of superantigen-MHC complex with T-cell receptors causes polyclonal T-cell activation (up to 20% at a time)
  4. There is massive and dysregulated cytokine production (mainly TNF, IL-1, IL-6) termed as cytokine storm
  5. Interferon–gamma is also produced, which subsequently inhibits polyclonal immunoglobulin production

d. Shock and Tissue Injury:
Role of various cytokines:

  • IL-1: high fevers, myalgia
  • TNF: hypotension, edema
  • IL-2 and IFN-gamma: rash

Symptoms of Toxic Shock Syndrome:

  1. High fever and chills
  2. Hypotension
  3. Vomiting and Diarrhea
  4. Erythematous rashes leading to desquamation and hyperemia of mucous membranes
  5. Myalgia and elevated serum creatine phosphokinase
  6. Redness of eye, mouth, throat
  7. Confusion
  8. Multiple organ dysfunction

Diagnosis and Treatment:

Toxic shock syndrome – Emedicine Medscape
A textbook of Microbiology – Chakraborty

About Author

Sulabh Shrestha

Intern doctor and Medical Blogger Sulabh Shrestha


  • My daughter died of tampon related TSS last summer; she was diligent about hygiene, used only regular tampons and changed very often for fear of TSS. If you are young (under 30) you most likely don’t yet have the antibodies against the toxins so please use 100% cotton tampons only. It’s rayon in the tampons that make toxins. Toxin production begins 2 hours after putting in a tampon and changing tampons doesn’t remove it; it waits inside for the next tampon to keep getting stronger. Your body needs 8 hours tampon free to let this toxin dissipate. This is why you should never, ever sleep in a tampon.
    Scientific evidence proves that 100% cotton tampons produce no toxins and are totally safe. These are available at health food stores and online.
    I have put together a group of 42 recent TSS surviving victims and parents of lost victims. If I personally know that many, how many are there really?
    In memory of Amy Rae Elifritz 10/16/89 – 6/13/10

    • We are sorry to hear about that.
      And the Initiative you have taken is Praise worthy and Inspiring.
      Keep it up.

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