**11. Toxic shock syndrome**

Toxic shock syndrome is a rare entity primarily occurring in menstruating women and caused by exotoxins produced by penicillinase-producing non invasive Staphylococcus aureus of phage type 1. It is associated with use of super absorbent tampons, especially if left in place for long. Tampon use may also excoriate the cervical and vaginal mucous membranes, thereby encouraging absorption of the exotoxin.

Non-menstrual toxic shock syndrome has been reported with prolonged use of contraceptive diaphragm or sponge [48], after delivery, laser therapy for condylomata acuminatum [49] and non-gynaecological surgery.

Toxic shock syndrome can also be caused by some streptococcus species, including Strepto‐ coccus viridans which causes a more fulminant disease with high mortality.

The clinical manifestations of toxic shock syndrome are diverse and these often develop rapidly in otherwise healthy persons. These include sudden onset of high fever, hypotension, and associated symptoms like vomiting, diarrhoea, myalgia, abdominal pain, and headache. A characteristic "sunburn-like" rash, a diffuse maculopapular erythroderma, appears over the face, trunk and proximal extremities over a period of 5-14 days, which later desquamates, especially over the palms and soles during convalescence. Multi-systemic involvement is typical and these include coagulopathy, renal, hepatic, muscular, cardiovascular, neurological and respiratory systems.

On taking a history, ask the patient if she is menstruating or using tampons. A vaginal examination should be performed and any foreign body in the vagina such as tampon or contraceptive device should be removed.

The diagnosis of toxic shock syndrome is usually clinical. A full septic and biochemical screen should be done to exclude multiorgan failure. Isolation of the exotoxin for Staphylococcus aureus is pathognomonic.

Treatment entails aggressive supportive therapy, preferably in an intensive care unit. Fluid resuscitation is necessary, and vasopressors, packed red cells and coagulation factors, me‐ chanical ventilation and haemodialysis may be required. Antibiotics, given intravenously, are used for 10-14 days to eradicate the organism. Protein synthesis inhibitors such as clindamycin which suppress toxin production are more effective than cell wall active agents like betalactams. Cephalosporins or beta-lactamase-resistant penicillins like nafcillin or oxacillin, and vancomycin (for penicillin-allergic patients) may also be used. Since toxic shock syndrome is toxin related, antibiotic treatment is not directly effective, but it reduces the bacterial load and ultimately prevents further toxin production.
