Toxic shock syndrome: causes in people with burn wounds

Toxic shock syndrome (TSS) is a rare complication resulting from colonisation or infection with a toxin-producing strain of Staphylococcus aureus. It was first described in 1978 by Todd et al who saw seven cases of TSS in young children with similar symptoms (fever, vomiting, diarrhoea, rash) that progressed to disseminated intravascular coagulation, shock and multi-organ failure. It was soon confirmed in five of the seven cases, that the syndrome was a result of infection associated with S. aureus of phage group 1 (Todd et al, 1978). It was shown that toxic shock syndrome toxin-1 (TSST-1) was involved in the pathogenesis of the syndrome (Bergdoll et al, 1981; Schlievert et al, 1981; Bergdoll and Schlievert, 1984) and since then there have been reported cases associated with other staphylococcal exotoxins, namely enterotoxin A, B and C (SEA–C) (Yaqoob et al, 1990). In 1980, after a strict definition of TSS was devised by the Centers for Disease Control and Prevention in Atlanta, USA (Chesney et al, 1981), there were hundreds of notified TSS cases in young women associated with menstruation. Epidemiological studies in the US showed that this sudden increase was due to the introduction of a highly absorbent tampon containing carboxymethylcellulose, RelyTM, produced by Proctor and Gamble (Schlievert et al, 1984). Subsequently these were shown to increase production of TSST-1 by S. aureus in vitro (Lee et al, 1987) and were recalled and discontinued in 1980 which led to a subsequent decrease in the incidence of menstrual-related TSS (MTSS) (Schuchat and Broome, 1991) (Figure 1). In addition, details of TSS and symptoms were included in all packs of tampons, raising awareness of the risks with users. Tampons are now predominantly made of cotton and rayon (Schuchat and Broome, 1991).