Menstrual Toxic Shock Syndrome
By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: The authors reviewed 102 patients with menstrual toxic shock syndrome requiring intensive care over 16 years in France. Despite the severity of illness, there were no deaths.
SOURCE: Contou D, Colin G, Travert B, et al; French m-TSS Study Group. Menstrual toxic shock syndrome: A French nationwide multicenter retrospective study. Clin Infect Dis 2022;74:246-253.
Contou and colleagues retrospectively examined cases of menstrual toxic shock syndrome (mTSS) seen in 43 adult and pediatric intensive care units in France over 16 years ending December 2020. Using a definition requiring acute circulatory failure and fever occurring in association with menstruation, with the absence of another source of sepsis, they identified mTSS in 102 patients. While not a criterion for diagnosis, all proved to be using vaginal tampons. Their median age was 18 years; 91 (89%) had no comorbid condition. Their median duration of symptoms before intensive care unit (ICU) admission was three days, at which time their median body temperature was 39.4°C and 87% had a rash, with mucous membrane involvement in one-half. Their median white blood cell count was 16,000 cells/µL, while the median serum procalcitonin concentration was 31 µg/L. Abdominal-pelvic computerized tomography was performed in 42 patients, and 10 (18%) had colitis, eight (15%) had intraperitoneal fluid, three (5%) had mesenteric adenitis, and two (4%) had terminal ileitis; two patients underwent exploratory laparotomy. No patients had skin desquamation at the time of ICU admission, but this subsequently occurred in 12 (12%) patients.
Blood cultures obtained on ICU admission all were negative, while methicillin-susceptible Staphylococcus aureus (MSSA) was recovered on culture of vaginal samples from 92 (96%) of 96 patients. Of the 92 isolates, 76 were screened for the presence of toxin gene sequences. The gene sequence tstH, which encodes toxic shock syndrome toxin-1 (TSST-1), was detected in 66 (87%), while 41 (64%) carried an enterotoxin gene. In addition to a semisynthetic penicillin, an “antitoxin antibiotic,” such as clindamycin, was administered to 81 (79%) patients and eight (8%) received intravenous immunoglobulins. Eighty-six (84%) and 21 (21%) required vasopressor therapy and invasive mechanical ventilation, respectively. There were no deaths.
The authors examined the cases relative to the Centers for Disease Control and Prevention (CDC) criteria for TSS and found that none met the CDC definition of confirmed TSS, while 53 could be classified as probable TSS.
COMMENTARY
The incidence of mTSS has decreased dramatically over the last decades despite the continued use of tampons by a majority of age-relevant women in the United States, as well as the use of menstrual cups by some.1 At the same time, toxin gene carriage in S. aureus persists. Parrish and colleagues examined 252 MSSA and 459 methicillin-resistant Staphylococcus aureus (MRSA) isolates from 531 children (one of whom had TSS) between 2008 and 2017 and found that 43 (6%) isolates encoded the TSS gene.2 Of the 43, 42 were MSSA isolates and only one was a MRSA isolate (P < 0.001).
There is no single test for the diagnosis of staphylococcal TSS, and the authors demonstrated that the CDC definition, which is meant for surveillance rather than diagnostic purposes, is insensitive in this regard. There are potentially diagnostic confounding factors in the cases reviewed by Contou et al, such as the abdominal-pelvic computed tomography findings, at least some of which, such as the peritoneal fluid, likely are related to the capillary leak that may occur with TSS. Contrary to the usual interpretation of elevated procalcitonin levels, marked increases were seen in these cases in the absence of invasive bacterial infection.
REFERENCES
- Schlievert PM, Davis CC. Device-associated menstrual toxic shock syndrome. Clin Microbiol Rev 2020;33:e00032-19.
- Parrish KL, Wylie KM, Reich PJ, et al. Carriage of the toxic shock syndrome toxin gene by contemporary community-associated Staphylococcus aureus isolates. J Pediatric Infect Dis Soc 2019;8:470-473.
The authors reviewed 102 patients with menstrual toxic shock syndrome requiring intensive care over 16 years in France. Despite the severity of illness, there were no deaths.
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