Toxic shock syndrome

Also called TSS

A sudden, overwhelming reaction to bacterial toxins. Rare, fast, and not only about tampons.

What it is

A rare but rapidly progressive illness caused by toxins released by staphylococcal or streptococcal bacteria, producing a body-wide inflammatory reaction and organ failure.

It became known through tampon use in the 1980s, and that association still exists, but roughly half of cases now have nothing to do with menstruation. Causes include wounds, burns, surgical sites, boils and abscesses, nasal packing, insect bites, chickenpox, childbirth, and any skin breach.

It is very fast. Somebody can go from feeling unwell to critically ill within 24 to 48 hours, which is why the advice is to seek help urgently rather than wait.

The picture is a sudden high fever with a widespread sunburn-like rash, vomiting or diarrhoea, dizziness and confusion. A characteristic later feature is peeling of the skin on the palms and soles, one to two weeks afterwards, which is a diagnostic clue after the event rather than a warning.

Anybody who has had it is at risk of getting it again and should avoid tampons and menstrual cups permanently.

Treatment is intensive care, intravenous antibiotics and removing the source, and outcomes are good when it is caught early.

Signs you might notice

Sudden high fever, usually above 39C.

A widespread red rash that looks like sunburn, including on the palms and soles.

Vomiting and diarrhoea.

Dizziness, fainting, or a low blood pressure.

Confusion or drowsiness.

Muscle aches, sore throat, headache.

Peeling of skin on the hands and feet, one to two weeks later.

**999 or A and E immediately.** Remove a tampon if one is in place and take it with you.

Say toxic shock syndrome; it is rare enough that naming it prompts the right thinking.

In a child with chickenpox, sudden high fever with a spreading red rash and rapid deterioration is an emergency.

How it can affect day-to-day life

The message about tampons is often given as a warning and rarely as practical instruction. What matters is using the lowest absorbency needed, changing regularly, washing hands before and after insertion, and not leaving one in overnight for long periods or forgetting one.

A forgotten tampon is a genuine and common cause, and the response should be embarrassment-free removal and assessment, not judgement.

Menstrual cups carry a small risk too, and should be emptied and cleaned as directed.

For anybody with a wound, burn or recent surgery, sudden fever with a rash is the pattern, and post-operative patients and their families should be told.

For someone who has had it once, permanent avoidance of tampons and cups is the advice, and it should be recorded on the GP record.

Supporting someone well

Go to A and E for sudden high fever with a widespread red rash, especially with vomiting, dizziness or confusion.

Remove a tampon if one is in and bring it.

Use the lowest absorbency tampon needed, change it regularly, and alternate with pads, particularly overnight.

Wash hands before and after inserting anything.

Never leave a tampon in longer than the packet advises, and see a clinician without embarrassment for a retained one.

For a wound or after surgery, treat sudden fever with a rash as urgent.

For a child with chickenpox who becomes suddenly much more unwell, go straight to hospital.

After an episode, avoid tampons and cups permanently and have it recorded.

Where to get help

999 or A and E immediately.

A GP practice or sexual health clinic for a retained tampon; this is routine and nobody minds.

UK Sepsis Trust for the overlapping sepsis warning signs.