Snapshot A previously healthy 18-year-old female comes into the acute care clinic with a day history of nausea, vomitting and diarrhea. She admits to currently menstruating and using tampons, which she does not change frequently. Temperature is 103°F (39.4°C), blood pressure 95/60 mmHg and pulse is 108/min. She is ill appearing on exam. Skin evaluation reveals a diffuse macular erythematous rash. Complete blood cell findings included a WBC of 14,000/mm3. Blood cultures were negative. Introduction Toxic shock syndrome (TSS) caused by pre-formed S. aureus toxin TSST-1 acts as a superantigen → non-specific clonal T-cell activation and cytokine outpouring Associated with high absorbency tampon use in reproductive females Seen in surgical and postpartum would infections and burns Presentation Symptoms occurs within 5 days of onset of menstrual period in women using tampons fever, vomiting, diarrhea Physical symptoms hypotension diffuse, macular erythematous rash desquamation of palms and soles occurs during recovery conjunctival-scleral hemorrhage Evaluation Clinical diagnosis Labs culture wound and mucosal sites negative blood and CSF cultures Differential Streptococcal toxic shock syndrome caused by pyogenic exotoxin A and C of S. pyogenes acts as a superantigen → non-specific clonal T-cell activation and cytokine outpouring Rocky mountain spotted fever Meningococcemia Treatment Rehydration Remove offending agent menstrual products (e.g., tampons, nasal packing) infected tissue Intravenous antibiotics clindamycin and vancomycin or linezolid change antibiotic once drug-sensitivities are obtained Prognosis, Prevention, Complications Prognosis menstrual TSS mortality declined nonmenstrual TSS mortality seems to remain stable Prevention not well established Complications renal involvement CNS manifestations