The Wisconsin Department of Health Services (DHS) has identified four cases of Toxic Shock Syndrome (TSS) related to super absorbency tampon use since July 2022. In typical years, 0 to one cases of TSS are reported to DHS; the last year when more than one case of TSS was confirmed was 2011.

The recent cases were identified in adolescent girls and young women, who were between the ages of 13 and 17. All patients presented for emergency care within one to two days of super absorbency tampon use with hypotension, fever, and evidence of organ dysfunction in three or more systems (see case definition below). All four patients required hospitalization for treatment and subsequently recovered.   

TSS is a rare, but serious clinical syndrome, caused by a bacterial infection due to Staphylococcus aureus or Streptococcus pyogenes. TSS is characterized by a progressive clinical course with symptoms including sudden fever, vomiting, diarrhea, dizziness, muscle aches, low blood pressure, rash, and shock with multi-organ dysfunction. Use of super absorbency tampons, of varying brands, was the only commonality between cases.

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Information for Clinicians

DHS is asking all physicians to be especially aware of early signs of TSS in individuals who use tampons presenting for care. Health care providers should elicit information on menstruation and tampon use, collect clinical specimens (vaginal specimens for bacterial culture) early in evaluation, and educate your patients, and their parents, on appropriate tampon usage and risk of TSS. Appropriate tampon use includes using the lowest absorbency tampons, changing tampons every four to six hours, and avoiding use of tampons overnight.

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Case Definition

Toxic Shock Syndrome (TSS, other than streptococcal) should be reported to DHS for any patient that meets the following CDC case definition:

• Fever with temperature greater than or equal to 38.9°C; AND
• Rash; AND
• Desquamation 1-2 weeks after onset of rash; AND
• Hypotension: systolic blood pressure less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years; AND
• Evidence of clinically severe illness requiring hospitalization, with involvement of 3 or more organ systems from the list below:
• Gastrointestinal (e.g. vomiting or diarrhea at onset of illness)
• Muscular (e.g. severe myalgia, or creatine phosphokinase level at least twice the upper limit of normal)
• Mucous membrane (e.g. vaginal, oropharyngeal, or conjunctival hyperemia)
• Renal (e.g blood urea nitrogen or creatinine at least twice the upper limit of normal or urinary sediment with pyuria in absence of urinary tract infection)
• Hepatic (e.g total bilirubin, alanine aminotransferase enzyme, or asparate aminotransferase enzyme levels at least twice the upper limit of normal for laboratory)
• Hematologic (e.g platelets less than 100,000/mm³)
• Central nervous system (e.g disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent)
• Negative results for blood or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus) OR negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles

Toxic Shock Syndrome is a category II reportable condition in Wisconsin. Please report cases of TSS to your local health department. Questions regarding this Health Alert may be directed to the Bureau of Communicable Disease at DHS by calling 608-267-9003 or via email to Susann.AhrabiFard@dhs.wisconsin.gov or Musheng.Alishahi@dhs.wisconsin.gov.