Toxic Shock Syndrome – The story of an unlikely culprit in the 1980s
What is Toxic Shock Syndrome?
This post combines two subjects that absolutely fascinate me, and hopefully you; the history of a disease, and its pathophysiology (medical observations + mechanism acting within the organism).
Toxic Shock Syndrome, or TSS, is an illness characterized by the body’s response with high fever, low blood pressure, confusion and/or stupor. The sudden drop in blood pressure is capable of depriving organs of oxygen, and can lead to death.
A rash accompanies these symptoms, resembling a sunburn around the lips, mouth, eyes, palms and soles.
It’s caused by a bacterial toxin; usually originating from overgrown Staphylococcus aureus or Streptococcus pyogenes, the organisms that we associate with “Staph” or “Strep”.
The manifestation of this illness is somewhat of a horror story; its severity frequently warrants hospitalization, even the emergency room, for aggressive fluid regulation, ventilation, kidney replacement or removal, and treatment of multiple organ failure. Yikes! The outcome can be fatal in a matter of hours.
The term toxic shock syndrome was first used in 1978 by a Denver pediatrician to describe the illness in seven of his patients, ages 8-17. Long story short, the pediatrician suspected that a bacterial toxin may be involved, since the bacterium could be isolated from the patients’ mucous, but not the blood. A study, and literature search, ensued, revealing similar cases as far back as 1927 that hadn’t been diagnosed as TSS.
Here comes the unlikely culprit: The authors of the study failed to consider that the women with TSS were, at the time, menstruating.
Later that year, P&G, a company based in Cincinnati, introduced superabsorbent Rely tampons to the United States market. The introduction of the product was in response to women’s demands for tampons that could contain an entire menstrual flow without leaking, or needing to be replaced.
For those of you women reading this, I am sure you are thinking, as I am, “If only!” right?
Rely tampons used carboxymethylcellulose and compressed polyester for absorption; a design which allowed for nearly 20 times its own weight in fluid to be absorbed as it blossomed inside that vagina.
In the late 1970s and early 1980s, TSS began to make headlines after the deaths of several young women.
In January of 1980, the CDC received numerous reports of TSS, mostly in menstruating women, who’d used the Rely tampons and left them in over the course of their menstrual cycle. In September of that year, the CDC reported that users of Rely were at risk for developing TSS, and P&G recalled Rely.
However, it soon became clear that Rely was not the only culprit.
Regardless of the chemical composition or the brand of tampon, there seemed to be a correlation between higher absorbency of tampons and TSS.
Rely was the exception; the risk for TSS was still higher when corrected for its absorbency, due to the strange ability of carboxymethylcellulose to filter the bacterial toxin.
Today, the CDC has stopped tracking TSS, though there was again a rise in cases reported in the early 2000s; eight deaths in California in 2002, and four deaths per year in three consecutive years following that. The authors of one study attribute the rise to the removal of warnings by manufacturers not to leave tampons in overnight.
A tampon saturated with blood is an ideal place for the rapid growth of bacteria; an ideal place to release their poisons into the blood stream. The progression of the disease stems from a superantigen – allow me to explain.
Superantigens are peptide or protein molecules released in this case, by bacteria, and can react with the cells of the immune system in unprocessed form, in contrast to conventional peptides that require uptake and processing by the immune cell prior to presentation on the cell surface to the rest of the immune system.
There is a nonconventional, and nonspecific, recognition by the other cells of the immune system that takes place; this nonconventional binding can activate up to 30% of peripheral immune cells, and elicit a massive immediate response.
The rapid activation of immune cells leads to inflammation and severe perturbations in organ function that are manifested as severe clinical diseases – TSS, in this case.
So what have we learned today? Ladies, don’t leave your tampon in for more than four hours, just to be safe!
Also note the description of absorbency on the package; the terms “junior”, “regular”, “super”, and “super plus” are FDA standardized. Judging by their history, the more absorbent tampons seem to pose higher risk to women who have heavy menstrual cycles – take them out sooner, rather than later.